.A.    TK/EJLTISB 


ON 


OPHTHALMOLOGY 


FOR    THE 


GENERAL     PRACTITIONER. 


SECOND    EDITION,    REVISED  AND    ENLARGED. 
WITH    140    ILLUSTRATIONS. 


BY 


^X)OL^^    J^XJT,    -Ml.T). 


J.   H.  CHAMBERS   &  CO., 

PUBLISHERS  AND  DEALERS  IN  MEDICAL  BOOKS,   ST.  LOUIS. 


OPTOMETRT 
UBRARY 


ENTERED  ACCORDING  TO  ACT  OF  CONGRESS,  IN  THE  YEAR  1 893,  BY 

JAMES  H.  CHAMBERS, 

IN  THE  OFFICE  OF  THE  LIBRARIAN  OF  CONGRESS,  AT  WASHINGTON,  D.  C. 


The  manner  in  which  the  first  edition  has  been  received  by 
the  public,  for  which  it  was  intended,  rendered  a  new  edition 
of  this  book  necessary  several  years  ago.  I  have  only  now 
been  able  to  rewrite  it. 

Although  this  second  edition  is  considerably  enlarged,  I 
have  tried  to  adhere  closely  to  the  original  plan,  to  make  it  a 
useful  guide  and  a  help  to  the  general  practitioner  who  may 
be  forced  to  take  care  of  certain  eye  diseases.  That  this  plan 
has  proven  a  very  acceptable  one,  I  have  received  ample 
evidence. 

In  this  second  edition  I  have  eliminated  the  illustrations  of 
eye-instruments,  as  every  instrument-makers'  catalogue  con- 
tains them.  On  the  other  hand  I  have  tried  to  give  particu-- 
larly  a  larger  number  of  practical  illustrations.  Those  of  them, 
which  are  not  my  own,  have,  as  far  I  was  able  to  find  it,  been 
credited  to  their  proper  source.  A  few  of  them  have  been 
copied  and  recopied  so  often  in  different  books,  that  their 
original  source  could  not  be  determined. 

Like  the  first  edition,  this  second  one  is  not  intended  for  the 
specialist.  That  it  may  be  useful  to  the  general  practitioner, 
has  been  and  is  my  desire. 

June,  1893.  ADOLF   ALT. 


CONTENTS. 
CHAPTER   I. 

•  ANATOMY    OF    THE     EYE. 

PARAGRAPHS. 
Orbit;  Tenon's  Capsule;  Eye-Lids;  Conjunctiva;  Sclerotic;  Cornea;  Uveal 
Tract;  Optic  Nerve;  Retina;  Crystalline  Lens;  Suspensory  Ligament; 
Aqueous  Humor;  Vitreous  Body:  External  Muscles  of  the  Eyeball; 
Lachrymal  Apparatus;  Blood-Supply;  Nerves.    .*      .        .        .        .        §1—14 

CHAPTER    H. 

EXAMINATION     OF     THE     EYE. 

Eyelids;  Lachrymal  Apparatus;  Conjunctiva;  Cornea;  Aqueous  Humor; 
Iris;  Crystalline  lens;  Focal  or  Oblique  Illumination;  Acuteness  of 
Vision;  Visual  Field;  Light-Sense;  Color-Sense;  Intra-Ocnlar  Ten- 
sion; Accommodation;  Refraction;  Ophthalmoscope;  Motility;  Diplo- 
pia; Insufficiency  of  the  Internal  Recti  and  Other  Muscles.        .        .      ^15—23 

CHAPTER   HI. 

DISEASES  OF  THE  EYELIDS. 

Erysipelas;  Herpes  Zoster;  Eczema;  Varioloid;  CEdema;  Blepharitis  Cili- 
aris;  Phthiriasis;  Hordeolum;  Chalazion;  Abscess;  Syphilitic  Ulcer; 
Warts;  Xanthelasma;  Epithelioma;  Sarcoma;  Teleangiectatic  and 
Angiomatous  Tumors;  Distichiasis;  Trichiasis;  Entropium;  Ectro- 
pium;  Ptosis  of  the  Upper  Eyelid;  Blepharospasmus;  Lagopethalmus; 
Blepharophimosis;  Wounds;  Emphysema;  Burns.       .        .  .      ^24 — ^36 

CHAPTER    IV. 

DISEASES     OF     THE    LACHRYMAL    APPARATUS. 

Lachrymal  Gland;  Hyper-Secretion;  Dakryo-Adenitis;  Neoplasms;  Cystic 
Distension  (Dakryops);  Drainage  Apparatus;  Epiphora;  Foreign 
Bodies  in  the  Lachrymal  Canaliculus;  Dakryo-Cystitis  Catarrhalis; 
Dakryo-Cystitis  Purulenta;  Strictures;  Lachrymal  Fistula;  Melano- 
Sarcoma  of  the  Lachrymal  Caruncle. §37 — 40 


VIII  OPHTHALMOLOGY. 

CHAPTER  V. 

DISEASES     OF    THE    ORBIT. 

PARAGRAPHS. 

Exophthalmus;  Periostitis  of  the  Walls  of  the  Orbit;  Hsemorrhages  into 
the  Orbital  Tissue;  Cellulitis  Orbitas,  Phlegmonous  Inflammation  of 
the  Orbital  Tissues;  Inflammation  of  Tennon's  Capsule;  Emphysema; 
Neoplasms. ^41 — 46 

CHAPTER   VI. 


MINOR    MANIPULATIONS    IN     THE    TREATMENT     OF     EYE-DISEASES. 

Cold  Applications;  Warm  Applications;  Leeching;  Removing  Discharge; 
Instillation  of  Medicated  Fluids;  Application  of  Astringent  Solutions; 
Application  of  Caustic  Solutions;  Application  of  Remedies  in  Sub- 
stance; Application  of  Ointments;  Inspergation  of  Medicinal  Pow- 
ders; Isolation;  Removal  of  Wild  Hairs;  Removal  of  Small  Foreign 
Bodies;  Insertion  of  Lid  Retractors;  Insertion  of  Artificial  Eyes; 
Bandaging;  Hints  for  Assistance  iu  Eye  Operations.  .        .        .      ^47 — 51 

CHAPTER   Vn. 


DISEASES      OF    THE     ORBIT. 

Hyperaemia;  Acute  Catarrhal  Conjunctivitis;  Chronic  Catarrhal  Conjunc- 
tivitis; Acute  Purulent  Conjunctivitis;  Chronic  Blenorrhoea;  Croupous 
Conjunctivitis;  Diphtheritic  Conjunctivitis;  Granular  Conjunctivitis 
(Trachoma);  Phlyctaenular  Conjunctivitis;  Exanthematic  Conjuncti- 
vitis;  Pemphigus;  Injuries;  Burns;  Tuberculosis;  Syphilitic  Ulcer; 
Amyloid  Degeneration;  CEdema;  Subconjunctival  Ecchymosis;  Sym- 
blepharon;  Anchyloblepbaron;  Lymphangiectasia;  Pinguecula;  Ptery- 
gium; Cysts;  Granuloma;  Epithelioma;  Sarcoma ^52 — 62 

CHAPTER   Vni. 

DISEASES   OF   THE    CORNEA. 

General  Remarks  on  Keratitis;  Phlyctaenular  Keratitis;  Fascicular  Kera- 
titis; Pustular  Keratitis;  Vesicular  Keratitis;  Keratitis  Filamentosa; 
Parenchymatous  Keratitis;  Syphilitic  Keratitis;  Abscess  of  the  Cor- 
nea; Hypopyon;  Ulcers  of  the  Cornea;  Malarial  Keratitis;  Neuro- 
paralytic Keratitis;  Scars  in  the  Cornea;  Tatooing;  Arcus  Senilis; 
Staphyloma  of  the  Cornea;  Conical  Cornea;  Injuries;  Burns;  Neo- 
plasms       ^63 — 70 


CONTENTS.  IX 

CHAPTER   IX. 

DISEASES    OF    THE    SCLEROTIC. 

PARAGRAPHS. 

Episcleritis;  Scleritis;  Staphyloma  of  the  Sclerotic;  Total  Staphyloma; 
Ciliary  staphyloma;  Equatorial  Staphyloma;  Posterior  Scleral  Staphy- 
loma; Buphthalmus;  Neoplasms;  Wounds;  Tumors.  .        ,        .      §71 — 73 

CHAPTER   X.      • 

DISEASES    OF    THE    IRIS. 

General  R*emarks  on  Iritis;  Plastic  Iritis;  Iritis  with  Spongy  Exudation; 
Serous  Iritis;  Purulent  Iiitis;  Gummatous  Iritis;  Tubercular  Iritis; 
Poisoning  by  Atropia;  Injuries;  Traumatic  Coloboma;  Iridodialysis; 
Neoplasms;  Cysts;  Sarcoma;  Mydriasis;  Miosis;  Hippus.  .        .      ^74 — 79 

CHAPTER    XL 

DISEASES    OF   THE    CILIARY    BODY. 

General  Remarks  on  Cyclilis;  Plastic  Cyclitis;  Serous  Cyclitis;  Purulent 

Cyclitis;  Gummatous  Cyclitis;  Neoplasms;  Sarcoma;  Injuries.  .  g8o 

CHAPTER   Xn. 

DISEASES    OF   THE    CHOROID. 

General  Remarks  on  Choroiditis;  Plastic  Choroiditis;  Serous  Choroiditis; 
Purulent  Choroiditis;  Panophthalmitis;  Phthisis  Bulbi;  Metastatic 
Choroiditis;  Neoplasms;  Gumma;  Tubercle;  Sarcoma;  Injuries; 
Isolated  Rupture  of  the  Choroid;  Haemorrhages.        .        .        .        .      |8i — 85 

CHAPTER    Xni. 

DISEASES    OF     THE    RETINA. 

Hypersemia;  Anaemia;  Embolism  of  the  Central  Retinal  Artery;  Throm- 
bosis of  the  Central  Retinal  Vein;  Detachment  of  the  Retina;  Pig- 
mentation of  the  Retina;  Pigmentary  Retinitis;  Syphilitic  Retinitis; 
Albuminuric  Retinitis;  Ursemic  Amaurosis;  Haemorrhages;  Glioma; 
Pseud  o-Glioma.  ........  .      ?86— 93 


X  OPHTHALMOL  OGY. 

CHAPTER   XIV. 

DISEASES    OF   THE    OPTIC    NERVE. 

PARAGRAPHS. 

Hypersemia;   Neuritis    Optica;     Atrophy;     Acquired    Color-Blindness; 

Amblyopia;  Amaurosis,  Hemianopsia;  Injuries;  Neoplasms;  Myxoma.       ^94 — 98 

CHAPTER   XV. 

DISEASES   OF   THE    CRYSTALLINE    LENS. 

General  Remarks;  Congenital  Cataract;  Zonular  Cataract;  Polar  Cataract; 
Total  Cataact;  Acquired  Cataract;  Soft  Cataract;  Cortical  Cataract; 
Nuclear  Cataract;  Diabetic  Cataract;  Secondary  Cataract;  Traumatic 
Cataract;  Dislocation  of  the  Crystalline  Lens;  Ectopia  Lenlis; 
Aphakia ^99—101 

CHAPTER   XVI. 

DISEASES    OF    THE    VITREOUS    BODY. 

Hyalitis;  Muscae  Volitantes;  Larger  Opacities;  New-Formation  of  Con- 
nective Tissue  Within  the  Vitreous  Body;  Synchisis  Scintillans; 
Haemorrhage ^102 

CHAPTER   XVII. 

GLAUCOMA. 

General  Remarks  on  Glaucoma;  Prodromal  Stages;  Chronic  Simple 
Glaucoma;  Acute  Inflammatory  Glaucoma;  Glaucoma  Fulminans; 
Chronic  Inflammatory  Glaucoma;  Glaucoma  Absolutum;  Secondary 
Glaucoma;  Haemorrhagic  Glaucoma;  Anatomical  Changes;  Theories.  §103 — 112 

CHAPTER  XVIII. 


INJURIES    OF   THE    EYEBALL    AND    THEIR    CONSEQUENCES. 

Injuries  "Without  Retention  of  a  Foreign  Body;  Antiseptic  Measures;  In- 
juries With  the  Retention  of  a  Foreign  Body  Within  the  Eyeball; 
Incarceration  of  Iris;  Prolapse  of  Iris;  Traumatic  Granuloma;  Cys- 
toid  Scar;  Traumatic  Cataract;  Removal  of  Foreign  Bodies;  Septic 
Inflammation;  Evisceration;  Neurotomy  and  Neurectomy;  Injuries 
by  Blunt  Force;  Dislocation  of  Lens. ^113- 


CONTENTS.  IX 

CHAPTER    XIX. 

SYMPATHETIC    OPHTHALMIA. 

PARAGRAPHS. 

General  Remarks  on  Sympathetic  Ophthalmia;  Sympathetic  Irritation; 
Sympathetic  Neuritis;  Sympathetic  Iritis;  Sympathetic  Irido-Cyclitis; 
Sympathetic  Irido-Choroiditis;  Sympathetic  Keratitis.       .         .        .  §ii8 — 123 

CHAPTER   XX. 

ERRORS  OF  REFRACTION  AND  ACCOMMODATION. 

Emmetropia;  Ametropia;  Hypermetropia;  Myopia;  Astigmatism;  Aniso- 
metropia; Accommodation;  Presbyopia:  Paialysis  of  the  Accommo- 
dation; Spasm  of  the  Accommodation §124 — 134 

CHAPTER    XXI. 

DISEASES    OF    THE   EXTERNAL    MUSCLES    OF    THE    EYE. 

Consideration  of  the  Normal  Condition  and  Action  of  the  Muscles; 
Diplopia;  Paralysis;  laralytic  Strabismus;  Muscular  Strabismus; 
Convergent  Strabismus;  Divergent  Strabismus;  Insufficiency  cf  the 
Recti  Muscles;  N>stagmus §135 — 144 

CHAPTER    XXII. 

ON    THE    DIAGNOSTIC    VALUE    OF   EYE-DISEASES    IN    INTRA- 
CRANIAL    AFFECTIONS. 

General  Considerations;  Ansemia  and  Hyperaemia  of  the  Optic  Nerve  and 
Retina;  CEdema  of  the  Optic  Papilla;  Optic  Neuritis  and  Neuro- 
Retinitis;  Progressive  Atrophy  of  the  Optic  Nerve;  Tubercles  in  the 
Choroid;  Conditions  of  the  Pupil;  Hemianopsia.        .        .        .        .^144 — 149 

CHAPTER   XXIII. 

DEVELOPMENT  OF  THE  EYE  AND  CONGENITAL  MALFORMATIONS. 

Development  of  the  Eye;  General  Considerations;  Microphthalmus; 
Megalophthalmus;  Keratoconus;  Dermoid;  Aniridia;  Coloboma; 
Korectopia;  Pupillary  membrane;  Persistent  Hyaloid  Artery;  Medul- 
lated  Nerve  Fibres;  Coloboma  of  Eyelids;  Kryptophthalmus;  Ptosis: 
Epicanthus;  Congenital  Tumors;  Albinism;  Heterochromia.     .        .  g  150— 156 


XII  OPHTHALMOL  OGY. 

CHAPTER   XXIV. 

EYE-AFFECTIONS    CAUSED    BY    DISEASES     OF     DISTANT   ORGANS    OR 
DISEASES    OF   THE    GENERAL    SYSTEM. 

PARAGRAPH^. 

Respiratory  Apparatus;  Circulatory  Apparatus;  Digestive  Apparatus; 
Uro-Poetic  Apparatus;  Genital  Organs;  Affections  of  the  Skin;  In- 
fectious Diseases;  Intoxications;  Diabetes;  Scrophulosis.  .         .  ^157 — 165 

CHAPTER    XXV. 

ON     THE     DETECTION     OF    ONE-SIDED    SIMULATED    BLINDNESS    AND 
CONGENITAL     COLOR  BLINDNESS. 

Methods  of  Detecting  Simulated  Blindness;  Holmgren's  Method  for  De- 
tecting Congen  tal  Color-Blindness gi66 — 167 

CHAPTER   XXVI. 

ON  ASEPSIS  AND  ANTISEPSIS DESCRIPTION   OF  THE  MOST  IMPORT- 
ANT OPERATIONS  ON  THE    EYEBALL  AND  THE  EYELIDS. 

Asepsis  and  Antisepsis;  Ansesihesia;  Tenotomy;  Advancement;  Enuclea- 
tion; Paracentesis  of  the  Cornea;  Abscision  of  a  Corneal  Staphyloma; 
Evisceration;  Sclerotomy;  Iridectomy;  Iridotomy;  Ext'^aclion  of  Cata- 
ract; Discission  of  the  Anterior  Lens-Capsule;  Pterygium  Operations, 
Operations  for  the  Cure  of  Symblepharon;  Ptosis-Operation;  Trichia- 
sis and  Entropium-Operations;  Ectropium-Operations;  Canthotomy 
and  Canthoplasty;  Blepharoplasty g  168  — 186 

CHAPTER    XXVII. 

ON  SPECTACLES. 

General  Considerations;  Action  of  Spherical  Lenses;  Cylindrical  Lenses; 

Prisms;  Hyperbolic  Lenses;  Protective  Glasses.  .        .        .        -^187 — 191 

CHAPTER    XXVIII. 

ON  THE  DRUGS  MOST  COMMONLY  USED    IN    OPHTHALMIC    PRACTICE. 

Atropine;  Homatropine;  Extractum  belladonnse;  Hyoscinum  hydroiodicum; 
Estrine;  Pilocarpine;  Cocainum  hydrochloricum;  Tropa-Cocainum; 
Bichloride  of  Mercury;  Aqua  Chlori;  Boracic  Acid;  Pyoktanine; 
Iodoform;  Aristol;  Zinc;  Nitras  Argenti;  Sulphate  of  Copper;  Yel- 
low Oxide  of  Mercury;  Red  Oxide  of  Mercury;  Calomel;  Jequiriiy; 
Extract  of  Jaborandi.  . .  ^192 — 196 


ILLUSTRATIONS. 


1.  The  l)ony  orbit  (Merkel)         -            -            -            -            -            -  i 

2.  Section  through  the  orbit  and  contents  (Gerlach)       -            -        •    -  4 

3.  Section  through  the  margin  of  upper  lid  (Gerlach)     -          .  -            -  7- 

4.  Superficial  layers  of  the  cornea  (Waldeyer)     -            -        .    -            -  10 

5.  A  portion  of  Descemet's  membrane                -            -            -            -  n 

6.  Iris-angle         ---.__-.  12 

7.  Corneal  nerves  (Waldtyer)     -            -            -            -            -            -  13 

8.  Ciliary  nerves  (Merkel)           -._.__  i^ 

9.  Bloodvessels  of  the  uveal  tract  (Leber)           -            -            _            _  14 
la  Pigment  epithelium  cells  (Schultze)                -            -            -            -  -15 

11.  Ciliary  body  Irom  a  near-sighted  e>e              _            -            _            _  16 

12.  Ciliary  body  from  a  far-sighted  eye    -             -            -            -            -  17 

13.  Pupillary  edge  of  the  iris        -_--»-  ijj 

14.  Distribution  of  the  blood  in  the  eye  (Leber)                           -            -  19 

15.  Optic  nerve  entrance                ..___.  20 

16.  The  layers  of  the  retina  (Merkel)        -----  22 

17.  Macula  lutea  and  fovea  centralis  (Helmholtz)            _            _            _  23 

18.  Anterior  surface  of  the  adult  lens  (Arnold)                -            _            _  24 
17.  Lachrymal  canaliculi  (CJerlach)          -----  26 

20.  Distribution  of  blood-supply  in  the  orbit  (Merkel)                -            -  28 

21.  Oblique  illumination  (Meyer)              _            -            _            .            _  36 

22.  Visual  field  (Landolt)              ------  38 

23.  Ophthalmoscopic  appearance  of  the  fundus  (Jaeger)             -            -  40 

24.  Action  of  ophthalmoscopic  mirror      -----  41 

25.  Operation  for  blepharoplasly  by  sliding  flaps  (Knapp)          -  51 

26.  Operation  for  blepharoplasty  by  sliding  flaps  (Kna;  p)          -            -  52 

27.  Hotz's  operation  for  trichiasis            .            -            .            -            -  54 

28.  Green's  operation  for  trichiasis  and  entropium          -            _            ,  55 

29.  Adam's  operation  for  ectropium          -----  57 

30.  Panas'  operation  for  ptosis      -            -            -                        -            -  59 

31.  Tarsorraphy     --------  60 

32.  Canthoplasty                -__---_  61 

33.  Bowman's  lachrymal  probes                -----  71 

34.  Cupola  of  lachrymal  sack  (Gerlach)                -            -            -            -  73 

35.  Prout's  wire  mask        -------  90 

36.  Hypertrophied  papillae  in  blenorrhoic  conjunctivitis  (Saemisch)      -  98 

37.  Papillary  trachoma  (Saemisch)            -            -            -'           -            -  104 

38.  Trachoma  granule       -            -            -            -            -            -            -  104 

39.  Pannus  trachomatosus              -            -    .        -            -            -            -  106 

40.  Phlyctaenular  conjunctivitis  (Dalrymple)         _            _            -            -  ili 

41.  Pter}gium  internum    -            -            -            -.-            -            -  117 


XIV  OPHTHALMOL  OGY. 

FIGURE.  PAGE. 

42.  Pigmented  episcleral  sarcoma             -            -            -            -  -  121 

43.  "Keratitis  filamentosa  (Nuel)                _            .            _            -  -  124 

44.  Corneal  abscess           -            -            __            _            -  -  128 

45.  Corneal  ulcer                -            -                         -            -            -  -  131 

46.  Corneal  scar    -            -            -            -            -            -            -  -  134 

47.  Corneal  staphyloma    -            -            -            -            -            -  -  135 

48.  Keratoconus                 -            -            -            -            -            -  -  137 

49.  Ciliary  scleral  staphyloma      -            -            -            -            -  -  140 

50.  Posterior  scleral  staphyloma                ._            -            -  -  141 

51.  Posterior  synechise  in  plastic  iritis      -----  144 

52.  Fibrino-plastic  iritic  newformation    -            -            -            -  -  145 

53.  Conjunctival  hypersemia  (Dalrymple)  -  -  -  -  146 
34.  Episcleral  and  ciliary  hypersemia  -  -  -  -  -  146 
55"  Crater-shaped  ins        -            -            -            --            -  -  148 

56.  Gumma  of  the  iris       -            -            -            -            -            -  -  149 

57.  Iridialysis        -            -            -            -            -            -            -  -  152 

58.  Plastic  cyclitis              -            -            -            -            -            -  -  1 56 

59.  Melanotic  sarcoma  of  ciliary  body     -            -            -            -  -  157 

60.  Histological  appearance  of  plastic  choroiditis            -            -  -  158 

61.  Ophthalmoscopic  appearance  of  plastic  choroiditis  (Foerster)  -  159 

62.  Phthisis  bulbi              -            -            -            -            -            -  -  162 

63.  Melanotic  sarcoma  of  the  choroid      -            -            -            -  -  164 

64.  Isolated  rupture  of  the  choroid  (Knapp)        -            .            -  -  165 

65.  Thrombosis  of  the  central  retinal  vein  (Michel)        -            -  -  168 

66.  Detachment  of  retina  (Wecker  and  Jaeger)                -            -  -  169 

67.  Total  detachment  of  retina     -            -            -            -            •  -  170 

68.  Ophthalmoscopic  appearance  of  retinitis  pigmentosa  (Liebreich)  -  172 

69.  Ophthalmoscopic  appearance  of  albuminuric  neuro-retinitis  -  174 

70.  Glioma  of  the  retina                -            -            -            -            -  -  176 

71.  Interstitial  optic  neuritis          -            -            -            -            -  -  178 

72.  Ophthalmoscopic  appearance  of  disk  in  optic  neuritis           -  -  179 

73.  Atrophy  of  the  optic  nerve      -            -            -            -            -  -  180 

74.  Myxoma  of  the  optic  nerve    -            -            -            -            -  -  183 

75.  Congenital  lamellar  cataract                -----  184 

76.  Congenital  anterior  polar  cataract  and  coloboma  of  the  iris  -  186 

77.  Cortical  cataract           ---.-..  188 

78.  Nuclear  cataract          -            -            -            -            -            -  -  189 

79.  Secondary  cataract      -            -            --            -            -  -  192 

80.  Dislocation  of  lens  into  the  anterior  chamber            -            _  .  193 

81.  Dislocation  of  Isns  into  the  vitreous  body      -            -            -  -  193 

82.  Ophthalmoscopic  appearance  of  a  glaucomatous  excavation  -  201 

83.  Histological  appearance  of  very  deep  glaucomatous  excavation  -  214 

84.  Adhesion  of  periphery  of  iris               -----  205 

85.  Swollen  ciliary  body  in  glaucoma      -----  205 

86.  Atrophic  iris  and  ciliary  body  in  glaucoma    -            -            -  -  206 

87.  Incarceration  of  iris    -            -            -            -*-            -  -  216 

88.  Prolapse  of  iris            -------  210 

89.  Traumatic  granuloma  of  iris                -            -            -            -  -  211 

90.  Cystoid  scar    ------  -  212 


ILL  US TRA  TIONS. 


91.  Tilting  backwards  of  iris        -  -            -            -            -            -  218 

92.  Dislocation  of  the  lens  under  the  conjunctiva  -            .            .  218 

93.  Emmetropic  refraction  -            -            -          *  -            -            -  225 

94.  Hypermetropic  refraction        ----__  226 

95.  Myopic  refraction        ----_>.  226 

96.  Snellen's  test-types     .------.  227 

97.  Ophthalmoscopic  appearance  of  myopic  eye  -            -            -  234 

98.  Posterior  scleral  staphyloma  -            -            -            -            -  235 

99.  Astigmatic  refraction  --..__  238 
100.  Origin  of  external  ocular  muscles  (Merkel)  .  .  -  244 
loi.  Insertion  of  external  muscles  on  the  sclerotic             -            -            -  225 

102.  Insertions  of  external  muscles  (Merkel)  -            _            _            _  246 

103.  Homonymous  diplopia  -            -            _            _            _            >  247 

104.  Heteronymous  diplopia  -            -            -            -            -            -  247 

IOC.  Paralysis  of  the  external  rectus           _            -            .            .            .  249 

106.  Paralysis  of  the  superior  oblique        -  -            _            -            .  250 

107.  Paralysis  of  the  internal  rectus  -            _            _            _            _  250 

108.  Paralysis  of  the  inferior  rectus  -            -            -            .            _  250 

109.  Paralysis  of  the  superior  rectus  -            -            -            -            -  251 
110-  Paralysis  of  the  inferior  oblique          -            -            -            -            -  251 

111.  Distention  of  the  inter-vaginal  space  by  intra-cranial  fluid  -  259 

112.  Organized  tissue  in  distended  inter-vaginal  space      -  -            -  259 

113.  Partial  decussation  of  optic  nerve  fibres  -            -            -            -  261 

1 14.  Homonymous  hemianopsia    ------  262 

115.  Heteronymous  hemianopsia  •_____  263 

116.  Primary  ocular  vesicle  -            -            -            -            -            -  264 

117.  Secondary  ocular  vesicle         -_.___  265 

118.  Later  stage  of  development  (J.  Arnold)  -            _            _            -  266 
119  Coloboma  of  the  iris                _-->_.  268 

120.  Remnants  of  pupillary  membrane      -----  269 

121.  Coloboma  of  the  choroid        ------  269 

122.  Coloboma  of  the  eyelids  (Manz)        -----  270 
126.  Epicanthus  internus  (Von  Ammon)                -            -            -            -  371 

124.  Advancement  of  external  rectus  -----  291 

125.  Removal  of  corneal  staphyloma  -----  293 

126.  Sclerotomy      -__-_--.-  294 

127.  Iridectomy      -  -            -            -            -            --            -  295 

128.  Simple  linear  extraction  ------  297 

129  Corneo-scleral  incision,  Graefe's  method        _            -            -            -  298 

130.  Simple  extraction,  corneal  incision    -----  299 

131.  Expulsion  of  cataract  ___---  299 

132.  Teale's  conjunctival  flaps  in  symblepharon  operation  -            -  301 

133.  Green's  tarsal  incision  -            -            -            -            -            -  302 

134.  Excision  of  skin  flap  (Green)  -            -            -            -            -  3^3 

135.  Ectropium  operation  ------  304 

136.  Concave  lens  in  hypermetropic  refraction      _  -            -            -  306 

137.  Concave  lens  in  myopic  refraction    -----  307 

138.  Convex  lens  in  presbyopia      -  -            -            -            -            -  Z^ 

139.  Prism  with  base  10 ward  temple  -----  309 

140.  Prism  with  base  toward  nose  -----  310 


OI^HZTEC^Xjl^^OILiOCa-^Z". 


CHAPTER     I.— ANATOMY     OF     THE     ORBIT,    EYE, 
AND     ITS     ADNEXA. 

§1.  The  orbit  is  a  quadrilateral  pyramidal  cavity  surrounded 
by  bony  walls,  which  separate  it  upwards  from  the  cranial  and 
frontal  cavities,  downwards  from  the  antrum  Highmorii  and 
inwards  from  the  nasal  cavity.     (See  Fig.  i). 


Fig.  I. —  (After  Merkel).  Right  orbit  viewed  from  in  front.  Showing  the  upper 
orbital  fissure  to  the  left  and  upward  and  next  to  it,  on  the  right,  the  optic 
canal.     To  the  left  and  downward  is  seen  the  lower  orbital  fissure. 

The  base  of  this  pyramid  is  formed  by  the  large  opening  in 
front.  Its  apex  lies  in  the  depth,  and  is  also  represented  by 
several  openings. 


2  OPHTHALMOLOGY.  ' 

The  rim  around  the  large  opening  in  front  is  called  the  or- 
bital margin,  and  we  speak  of  an  inner,  upper,  outer  and 
lower  orbital  margin.  The  last  three  of  these  margins  are 
slightly  overhanging  the  interior  of  the  orbit  and  have  a  sharp 
edge,  whilst  the  inner  one  is  rounded  off.  The  outer,  upper 
and  lower  margins  are  formed  of  very  hard  and  dense 
bone. 

Seven  different  bones  of  the  skull  and  face  help  together  in 
making  up  the  walls  of  the  orbit.  The  upper  wall  is  formed 
by  the  horizontal  portion  of  the  frontal  bone  and  a  small  part 
of  the  small  wing  of  the  sphenoidal  bone.  On  its  temporal 
side,  behind  the  superior  orbital  margin  we  find  in  this  wall  a 
small  depression  in  which  the  lachrymal  gland  is  situated, 
which  is  called  the  fossa  glandules  lacrymalis.  Another  small 
depression  lies  near  the  median  side,  in  which  the  trochlea  for 
the  superior  oblique  muscle  is  found.  This  is  called  \\\q,  fossa 
trochlearis.  Above  this  wall  lies  the  frontal  sinus  and  the 
cranial  cavity. 

The  inner  wall  consists  of  the  lamina  papyracea  of  the  eth- 
moid bone,  the  lachrymal  bone,  and  a  very  small  portion  of 
the  body  of  the  sphenoid  bone  near  the  apex.  In  its  most 
anterior  part  it  has  a  deep  depression  with  a  sharp  posterior 
and  anterior  edge,  the  fossa  lacry^nalis  in  which  the  lachry- 
mal sack  is  situated.  Its  anterior  edge  is  formed  by  a  pro- 
jection of  the  supramaxillary  bone,  the  posterior  one  by  the 
lachrymal  bone.  These  two  edges  are  joined  farther  down 
and  form  the  lachrymal  canal  for  the  lachrymal  duct.  In  this 
orbital  wall  we  find  two  openings,  the  foramen  ethmoidale  an- 
terius  for  the  nervous  ethmoidalis  and  the  anterior  vasa  eth- 
moidalia,  and  the  foramen  ethmoidale  posterius  for  the 
posterior  vessels  of  the  same  name. 

The  lower  wall  which  is  higher  on  its  nasal  than  on  its 
temporal  side,  consists  of  the  orbital  portion  of  the  supramax- 
illary bone,  the  orbital  portion  of  the  zygomatic  bone,  and  the 
orbital  portion  of  the  palatine  bone.  It  has  a  longitudinal 
groove  near  its  middle  line,  sulcus  infraorbitalis,  in  which  the 
infraorbital  nerve  and  artery  pass  forward  into  the  infraorbital 
canal.     Below  this  wall  lies  \ki^  antrum  of  Highmore. 

The  outer  wall  consists  of  the  temporal  portion  of  the  zygo- 


ANATOMY.  3 

matic  bone  and  of  the  temporal  wing  of  the  sphenoidal  bone. 
In  it  we  find  a  groove  for  the  nervus  zygomatico-temporalis 
and  one   or  two  openings  for  the  nervus  zygomatico-facialis. 

The  upper  orbital  margin  has  near  its  nasal  end  a  large  in- 
cision for  the  supraorbital  nerve  and  vessels,  and  a  smaller  one 
for  the  frontal  nerve  which,  coming  out  of  the  orbit,  go  to 
the  forehead. 

Below  the  nasal  end  of  the  lower  orbital  margin  is  the  open- 
ing of  the  infraorbital  canal  through  which  the  infraorbital 
nerve  and  artery  come  to  the  surface. 

At  the  apex  of  the  orbital  pyramid  lies  the  optic  foramen 
or  canal,  a  short  funnel-shaped  passa^re  for  the  optic  nerve  and 
ophthalmic  artery.  The  direction  of  this  canal  is  up — and 
inward. 

There  are,  furthermore,  near  the  apex  and  converging  to- 
wards it  two  fissures  where  the  outer  wall  is  joined  to  the  lower 
and  to  the  upper  one.  They  are  called  the  upper  and  lower 
orbital  fissures,  or  the  sphenoid  and  spheno-maxillary  fiss- 
ures. Through  the  upper  fissure  pass  the  motor  nerves  of 
the  eye,  and  the  ophthalmic  nerve  and  vein.  On  its  inner 
side  within  the  skull  lies  the  cavernous  sinus.  These  fissures 
vary  in  height  and  breadth. 

The  inner  walls  of  the  two  orbits  run  nearly  parallel  to  each 
other,  and  in  consequence  the  axes  of  the  two  cavities  con- 
verge towards  the  median  line. 

The  periosteum  of  the  orbital  cavity  is  formed  by  the  dura 
mater. 

This  membrane,  after  having  entered  the  orbit  through  the 
canalis  opticus  and  fissura  sphenoidea,  is  split  into  two  parts, 
one  of  which  serves  to  form  the  periosteal  coat  of  the  orbit, 
while  the  other,  in  the  main,  forms  the  dura  mater  sheath  of 
the  optic  nerve,  and  a  capsule  for  the  posterior  parts  of  the 
eye-ball,  called  Tenon' s  capsule.  This  capsule  ensheathes  about 
the  posterior  four-fifths  of  the  eye-ball  leaving  a  small  space  bare 
where  the  optic  nerve  and  the  ciliary  nerves  and  blood- 
vessels enter  it,  and  ends  in  front  near  the  limbus  conjunctivae 
by  joining  this  membrane.  It  is  a  serous  membrane,  lined 
with  a  layer  of  endothelial   cells.     The  serous  space,  which 


4  OPHTHALMOL  OGY, 

lies  between  it  and  the  eye-ball,  is  called   Tenon's  space.     (See 

Fig.  2). 

In  this  capsule  the  eye  moves  very  much  like  a  joint  in  its 
capsule,  although  numerous  fibres  traverse  this  space,  and  in- 
sert themselves  in  the  episcleral  tissue  and  Tenon's  capsule^ 
and  vice  versa. 


Fig.  2. — (After  Gerlach).  Horizontal  section  through  lids,  eyeball  and  orbit,  show- 
ing their  relative  positions,  also  Tenon's  capsule  and  the  lymph-sheaths  for 
the  internal  and  external  rectus  muscles. 

From  Tenon's  capsule  a  large  number  of  small  trabeculae 
run  back  into  the  periosteum  of  the  orbit.  Between  these 
trabeculse  lies  the  orbital  fat.  In  the  neighborhood  of  the  lach- 
rymal gland  they  contribute  to  the  formation  of  its  firm 
fibrous  capsule.  They,  furthermore,  help  to  keep  the  eye-ball 
and  the  other  contents  of  the  orbit  in  position. 

Tenon's  space  can  be  inflated  or  injected  from  the  subdural 
space  of  the  cranium.  Such  an  injection  shows  that  this  space 
ends  near  the  corneo-scleral  margin,  where  the  tissue  of 
Tenon's  capsule  goes  over  into  the  tissue  of  the  ocular  con- 
junctiva. 

The  external  muscles  of  the  eye-ball,  of  which  there  are  six 


ANATOMY.  5 

(the  rectus  superior,  inferior,  externus  \abducens'\  and  internus, 
and  the  obliquus  superior  and  inferior),  must  naturally  pierce 
this  capsule  to  reach  their  insertions  in  the  sclerotic,  and  they 
receive  a  sheath  from  it.  The  sheaths  of  the  recti  muscles  can 
be  traced  backward  into  the  orbital  fat  where  they  are  gradu- 
ally lost  in  the  perimysium.  The  sheath  of  the  superior  obli- 
que {trochlearis)  muscle  reaches  to  the  trochlea,  and  there 
joins  the  periosteum,  while  that  of  the  inferior  oblique  muscle 
hardly  reaches  as  far  back  as  the  orbital  adipose  tissue 
(Gerlach). 

The  layer  of  the  dura  mater  which  forms  the  periosteum  of 
the  orbit,  runs  forward  to  the  anterior  margins  of  that  cavity, 
where  it  passes  over  into  the  periosteum  of  the  surrounding 
bones.  It  also  gives  off  a  fascial  layer  for  the  eye-Hds,  called 
the  tarso-orbital  fascia.  The  orbital  periosteum  is,  for  the  most 
part,  only  loosely  connected  with  the  bone,  but  wherever  there 
is  an  aperture  in  the  orbital  walls,  and  also  at  the  orbital  mar- 
gins, its  attachments  are  very  firm. 

§2.  The  eye-lids  are  originally  a  duplicature  of  the  skin, 
growing  down  from  the  upper  and  up  from  the  lower  orbital 
margins  during  foetal  life.  The  part  of  this  fold  which  lies 
directly  upon  the  eye-ball  takes  on  the  character  of  a  muc- 
ous membrane,  the  palpebral  conjunctiva,  and  forms  with  the 
ocular  conjunctiva  a  cul-de-sac,  which  is  called  the  fornix  of 
of  the  conjunctiva. 

At  the  free  margin  of  the  lids  this  mucous  membrane  and 
the  cutaneous  outer  surface  pass  over  into  each  other,  in  the 
same  way  as  they  do,  for  instance,  on  the  lips.  The  free  mar- 
gins of  the  eye-lids  form  two  distinct  edges,  the  inner  one 
(toward  the  eye)  sharp,  the  outer  one  rounded  off.  Where  the 
upper  and  lower  eye-lids  join  each  other  in  the  horizontal  line, 
they  form  the  outer  and  inner  angles  of  the  palpebral  fissure, 
{outer  and  inner  canthus).  The  outer  angle  is  sharp;  the  in- 
ner is  rounded.  Behind  the  inner  angle  of  the  palpebral  fissure 
lies  a  small  reddish,  round  body,  called  the  lachrymal  caruncle. 
It  has  the  structure  of  the  cutis,  and  contains  fine  hairs  and 
sebaceous  glands.  The  fatty  secretion  of  these  glands  stems 
the  current  of  the  lachrymal  fluid  and  helps  to  direct  it  to  the 


6  OPHTHALMOL  0G\. 

channels  of  drainage.  On  the  temporal  side  of  the  caruncle  the 
conjunctiva  forms  a  semilunar  fold  with  the  concavity  directed 
toward  the  cornea  which  is  a  remnant  of  the  third  lid  or,  mem- 
brana  nic titans,  as  we  find  it  in  animals.  It  is  called  the  plica 
semilunaris. 

A  little  outwards  from  the  inner  angle  of  the  palpebral  fis- 
sure each  eye-lid  shows  at  the  inner  edge  of  the  margin  a 
small  papilla-like  elevation  with  a  small  aperture  at  its  apex. 
These  elevations  are  the  lachrymal  papillcE;  the  apertures  are 
the  lachrymal  puncta. 

The  cutis  of  the  eye-lids  is  thin  and  its  hairs  are  very  fine 
and  short.  The  subcutaneous  tissue  is  very  loose  and  contains 
no  fat. 

Between  the  conjunctival  and  cutaneous  surfaces  of  the  lids 
lie  the  tarsal  tissue,  the  muscular  layer,  nerves  and  blood-ves- 
sels. 

The  tarsal  tissue,  commonly  called  the  tarsal  cartilage,  lies 
close  upon  the  conjunctiva.  It  consists  of  dense,  tendon  like 
connective  tissue  and  is  really  no  cartilage.  This  tarsal  tissue, 
freed  from  its  surroundings,  has  a  more  or  less  semi-lunar 
shape.  In  the  upper  eye-lid  its  convexity  is  directed  upwards, 
in  the  lower  eye-lid,  downwards. 

Near  the  conjunctival  surface  a  number  of  glands,  the  Meibo- 
mian or  tarsal  glands,  lie  embedded  in  the  tarsal  tissue,  in  a 
direction  more  or  less  at  right  angles  to  the  lid  margins.  The 
orifices  of  the  ducts  of  those  glands  are  arranged  in  a  row,  at 
the  inner  edge  of  the  free  margin  of  each  eye-lid.  Their  se- 
cretion is  a  fatty  substance. 

Nearer  the  outer  edge  of  the  free  margin  of  the  eye-lid 
grow  the  cilia,  eyelashes.  They  are  short,  strong  hairs,  which 
are  curvilinear  in  form,  and  are  so  directed  that  those  of  the 
upper  and  lower  eye-lids  turn  their  convexities  toward  each 
other,  those  of  the  upper  lids  being  convex  downward,  those 
of  the  lower  lids  convex  upward.  They  differ  from  other  hair 
by  the  fact,  that  they  live  on  an  average  only  for  a  period  of 
of  from  60  to  100  days,  and  then  drop  off. 

The  conjunctiva  of  the  lids  is  closely  attached  to  the  tarsal 
tissue,  no  submucous  layer  intervening.  Where  the  tarsal  tissue 
ends,  submucous  tissue  makes  its  appearance,  being  very  loose 


ANATOMY. 


and  of  an  adenoid  character.  This  adenoid  tissue  is  thickest 
in  the  fornix  of  the  conjunctiva.  In  this  region  the  surface  of 
the  conjunctiva  is  wrinkled  and  folded,  and  numerous  mucipa- 
rous {Krause  and  Waldeyer)  glands  open  into  it. 


Fig.  3. — (After  Gerlach). — The  tissues  near  the  margin  of  the  upper  lid.  To  the  left, 
the  cutaneous,  to  the  right,  the  conjunctival  surface.  Next  to  the  conjuncti- 
val surface  lies  the  tarsal  tissue  in  which  is  seen  embedded  a  Meibomian 
gland  with  its  efferent  duct  opening  at  the  inner  edge  of  the  lid  margin;around 
it  are  seen  the  fibres  of  the  muscle  of  Riolanus.  Nearer  the  cutaneous 
edge  two  cilia  are  seen  and  a  modified  sudoriferous  gland.  To  the  right  of 
the  cutaneous  surface  lies  a  portion  of  the  orbicularis  palpebrarum  muscle. 

The  muscles  of  the  eye-lids  are  embedded  in  the  loose  con- 
nective tissue  on  the  outer  surface  of  the  tarsus.  The  most 
important  one  is  the  orbiadaris  palpebrarum.  This  is  a  very- 
broad,  thin  muscle,  covering  the  whole  area  of  the  eye-lids,  and 
reaching  somewhat  beyond  them  in  all  directions.  It  consists 
of  three  component  parts  which  are  called  the  palpebral,  the 
orbital  and  the  malar  portions.  The  orbicularis  acts  as  a 
sphincter  muscle,  contracting  the  palpebral  fissure  and  closing 


8  OPHTHALMOL  OGY. 

the  eye-lids.  A  small  portion  of  this  muscle,  which  lies  in  the 
tissue  between  the  roots  of  the  eyelashes  and  the  excretory 
ducts  of  the  Meibomian  glands,  is  called  the  ciliary  muscle  of 
Riolanus.  Its  function  seems  to  be  to  help  in  moving  the  se- 
cretion of  the  Meibomian  glands  to  the  lid-margin.  (See  Fig.  3). 

There  is,  furthermore,  a  non-striated  muscle  situated  in  both 
upper  and  lower  lids.  It  is  very  thin,  but  almost  as  wide  as 
the  lid,  lies  near  the  conjunctival  fornix,  and  its  fibres  run  at 
right  angles  to  the  lid-margin.  It  ends  on  one  hand  in  the 
tarsus,  on  the  other  in  the  subcutaneous  tissue.  After  its  dis- 
coverer it  is  called  Mueller' s  muscle,  or  the  superior  and  in- 
inferior  palpebral  muscle. 

Where  the  upper  and  lower  halves  of  the  orbicularis  muscle 
join  each  other  at  the  outer  and  inner  angles  of  the  palpebral 
fissure,they  form  the  ligamentum  palpebrale  externum  and  inter- 
num^ of  which,  however,  only  the  inner  one  is  a  real  hgament. 

At  the  upper  edge  and  along  the  whole  breadth  of  the  tar- 
sal tissue  of  the  upper  eye-lid  the  levator  palpebfce  superioris 
muscle  is  inserted  by  a  broad,  thin  tendon.  This  muscle  rolls 
the  uper  eye-lid  upward  and  backward  into  the  orbit,  and 
thus  opens  the  eye. 

§3.  The  ocular  conjunctiva  begins  at  the  fornix  and  ends  at 
the  cornea- scleral  margin  (/m3z/^  cornece).  Its  submucous  ade- 
noid tissue  is  loosely  connected  with  the  sclerotic  {episcleral 
iiss2ie).  No  glands  are  found  in  the  ocular  conjunctiva,  al- 
though its  epithelial  layer  contains  numerous  mucoid  cells. 

The  shape  of  the  eye-ball  is  nearly  spherical,  and  is  deter- 
mined by  the  so-called  hard  membranes  which  together  con- 
stitute its  outer  walls,  namely,  the  sclerotic  and  the  cornea. 

§4.  The  sclerotic  consists,  like  the  tarsus,  of  a  dense  con- 
nective tissue,  the  fibres  of  which  are  irregularly  interwoven, 
and  are  held  together  by  a  protoplasmic  cementing  substance. 
Embedded  in  this  latter  is  a  system  of  lymphatic  canals,  which 
enlarge  at  intervals  and  contain  large,  flat,  stellated  connec- 
tive-tissue cells.  It,  furthermore,  contains  nerves  and  blood- 
vessels. 

The  fibres  of  the  sclerotic  run  mostly  in  an  approximately 


ANATOMY.  9 

longitudinal  {meridional)  direction.  Fibres  running  in  a  circular 
{cequatorial)  direction  are  found  in  larger  quantities  only  around 
the  optic  nerve  entrance    and    near   the  corneo-scleral  margin. 

At  the  optic  nerve  entrance  the  sheaths  of  the  nerve  become 
merged  in  the  sclerotic.  There  is  no  large  opening  in  the  lat- 
ter membrane  to  admit  the  optic  nerve,  as  a  whole,  into  the 
eye-ball,  but  a  large  number  of  small  holes,  each  admitting  a 
bundle  of  nerve-fibres.  This  sieve-like  region  is  called  the 
lamina  cribrosa  of  the  sclerotic.  The  tendons  of  the  external 
muscles  of  the  eye-ball  are  lost  in  the  tissue  of  the  sclerotic  at 
their  insertions. 

The  sclerotic  has  an  endothelial  coat  on  its  outer  and  inner 
surface,  and  is  pierced  by  the  ciliary  nerves  and  arteries,  and 
by  the  vencB  vorticosce,  with  their  respective  lymph-sheaths. 

At  the  corneo-scleral  margin  the  tissue  of  the  sclerotic, 
which  is  only  translucent,  passes  over  into  the  transparent  tis- 
sue of  the  cornea,  but  in  such  a  manner  that  the  sclerotic 
tissue  slightly  overlaps  the  cornea  at  its  periphery.  The  man- 
ner of  the  junction  of  these  two  membranes  is  best  likened  to 
the  way  in  which  a  watch-crystal  sits  in  the  rim  of  the  watch. 

§5.  The  cornea  consists  of  fibres  of  a  perfectly  transparent 
modified  connective  tissue,  which  are  regularly  arranged  in 
bundles,  and  these  again  in  lamellae,  which  lie  more  or  less 
parallel  to  each  other,  and  are  all  united  by  the  same  proto- 
plasmic cementing  substance,  which  is  found  in  the  sclerotic. 
In  this  substance  are  enclosed  the  lymphatic  canals  of  the 
cornea,  which,  like  the  lamellae,  are  more  numerous  and  lie 
closer  together  toward  the  anterior  surface  of  the  cornea. 
They  have,  like  the  scleral  canals,  numerous  ampulla-like 
enlargements  {lacuncB),  in  which  are  contained  the  large,  flat 
many-branched  connective-tissue  cells  of  the  cornea  {corneal 
corpuscles).  At  the  corneo-sceral  margin  this  system  of  ca- 
nals goes  directly  over  into  the  similar  system  of  canals  in  the 
sclerotic. 

Near  the  outer  (anterior)  surface  the  layers  of  the  cornea  be- 
come more  compact,  and  finally  coalesce  to  form  a  layer, 
which  by  its  lack  of  cellular  elements  appears  like  a  distinct 
hyaline,  elastic  membrane.     This  is  called  Bowman' s  or  Reich- 


10 


OPHTHALMOL  OGY. 


erfs  layer.  (See  Fig.  4)  At  its  posterior  surface  the  cornea 
is  lined  by  a  thin  vitreous  membrane  called  Descemefs  mem- 
brane. This  is  an  elastic  membrane,  and  rolls  upon  itself, 
when  divided  or  separated  from  the  corneal  tissue. 


Fig.  4. — (After  Waldeyer).  Meridional  section  through  the  superficial  layers  of  the 
cornea  of  the  calf.  Shows;  Flattened  epithelial  cells;  prickle  and  poly- 
morphous cells;  basal  (club-shaped)  cells.  Below  the  epithelium,  Bowman's 
layer;  below  this,  the  corneal  tissue  proper  with  canals,  lacunae,  fixed  and 
wandering  cells. 


Upon  the  anterior  surface  of  Bowman's  layer  lies  the  cor- 
neal epithelium.  Descemefs  membrane  on  its  posterior  sur- 
face is  lined  by  a  single  layer  of  endothelial  cells. 

At  the  corneo-scleral  margin,  where  the  ocular  conjunctiva 
ends,  its  epithelium  goes  directly  over  into  the  epithelium  of 
the  cornea.  Bowman's  layer,  together  with  the  nearest 
corneal  lamellae,  is  split  into  fibrillae  and  becomes  merged  in 
the  subconjunctival  tissue.  Descemefs  membrane,  with  the  ad- 
joining layers  of  the  cornea,  is  similarly  split  into   fibrillae  at 


ANATOMY.  11 


the  periphery  of  the  cornea,  and  is  lost  partially  in  the  tendon 
of  the  ciliary  muscje  and  partially  in  the  iris.     On  their  way 


Fig.  5. — A  portion  of  Descemet's  membrane  partially  covered  with  endothelial  cells 
torn  from  the  cornea.  Its  fibres  form  (upwards)  the  network  of  the  so- 
called  ligamentum  pectinatum  of  the  iris. 

these  fibres  form  what  is  called  the  ligamentum  pectinatum  of 
the  iris.  (See  Figs.  5  and  6).  Between  the  fibres  of  this  so- 
called  hgament  lie  a  large  number  of  cavities,  which  are  called 
Fontana's  cavities.  These  cavities  communicate  toward  the 
outer  surface  with  the  canalicular  system  of  the  cornea  and 
sclerotic,  and  with  Schlemm's  canal,  a  larger-lymph  canal  em- 
bedded in  the  corneo-scleral  tissue;  on  the  other  side  they 
open  into  the  anterior  chamber. 

The  corneal  tissue  contains  blood-vessels  only  at  its  periph- 
ery, where  a  system  of  loops  of  capillaries  reaches  into  it  for 
the  distance  of  about  one  millimeter.  There  seem  to  be  two 
sets  of  these  loops,  one  in  the  deeper  layers  of  the  cornea 
and  one  more  superficially  situated.  The  arterial  vessels  which 
take  part  in  the  formation  of  these  loops  come  from  the  ante- 
rior ciliary  arteries,  and  anastomose  with  the  blood-vessels  of 
the  conjunctiva.  The  blood  is  carried  away  from  these  loops 
by  small  veins  which  empty  it  into  the  episcleral  and  by  this 
route  into  the  anterior  ciliary  veins. 


12  OPHTHALMOLOGY, 

The  cornea  at  its  periphery  is,  furthermore,  supplied  by 
a  number  of  larger  nervous  branches  which  come  from  the  con- 
junctival and  anterior  ciliary  nerves.     They  enter  near  the  pos- 


FiG.  6. — Meridional  section  through  the  corneo-scleral  margin  and  iris-angle,  show- 
ing the  manner  in  which  the  tissues  of  the  cornea  join  those  of  the  sclerotic, 
iris,  and  tendon  of  the  ciliary  muscle.  The  points  of  interest  are;  Schlemm's 
canal,  the  large  lymph-space  on  the  inner  side  of  the  sclerotic,  and  the 
fibres  into  which  Descemet's  membrane  is  split  up,  which  form  the  ligamen- 
lum  pectinatum  with  Fontana's  spaces  lying  between  meshes. 

terior  surface  of  the  cornea  and  lie  in  a  special  system  of  ca- 
nals. Soon  after  having  entered  the  corneal  tissue,  the  nerve- 
fibres  lose  their  double  contour,  and  the  main  stems  give  of 
branches  which  soon  form  a  network,  called  the  deep  stroma- 
plexus.  From  this  plexus  smaller  branches  rise  towards  the 
surface  of  the  cornea,  split  into  axis-cylinders  and  axis-fibrillae, 
and  after  having  formed  another  network  under  Bowman's 
layer,  called  the  superficial  stroma-plexus,  they  pierce  this  lay- 
er nearly  at  a  right  angle,  and   form  a  third  network  between 


ANATOMY. 


13 


the   epithelial  cells  (the  intra-epithelial  plexus),  and  are  there 
lost.     (See  Fig.  7). 


Fig.  7. — (After  Waldeyer).  Oblique  section  of  the  huooan  cornea  stained  with 
chloride  of  gold,  in  order  to  show  the  distribution  of  the  smaller  nerve- 
branches  within  its  tissue  and  epithelium. 

§6.  Next  to  the  inner  surface  of  the  sclerotic  lies  the 
uveal  tract,  the  vascular  membrane  of  the  eye-ball.  Although 
the  uveal  tract  consists,  in  the  main,  of  the  same  tissue  from 
one  end  to  the  other,  it  is  divided  into  three  distinct  parts,  the 
choroid,  the  ciliary  body  and  the  iris. 


Fig.  8. — (After  Merkel).  The  sclerotic  being  removed,  the  manner  in  which  the 
ciliary  nerves  pass  through  the  suprachoroidal  space  to  reach  the  anterior 
parts  of  the  eye,  is  shown. 

The  uveal  tract  firmly  adheres  to  the  sclerotic   around  the 


14 


OPHTHALMOL  OGY. 


optic  nerve  entrance  and  at  the  cornea-scleral  margin.  Be- 
tween these  two  attachments  it  is  slightly  separated  from  the 
sclerotic  by  the  supra-choroidal  space.  This  space  is  traversed 
by  innumerable  fibres  going  from  the  uveal  tract  into  the  scle- 
rotic and  vice  versa,  which  thus  form  a  delicate,  spongy  tissue 
containing  a  great  many  endothelial  cells.  When  the  choroid 
is  forcibly  detached  from  the  sclerotic  these  fibres  are  torn, 
and  the  part  of  them  which  then  adheres  to  the  sclerotic  has 
been  called  the  lamina  fusca,  while  the  part  adhering  to  the 
choroid,  is  known  as  the  lamina  suprachoroidea.  In  this 
spongy  tissue  the  ciliary  nerves  run  forward  to  the  ciliary 
body,  after  having  pierced  the  sclerotic  near  the  entrance  of 
the  optic  nerve.     (See  Fig.  8). 


Fig.  9. — (After  Leber).    Distribution  of  bloodvessels  in  the  uveal  tract. 

The  choroid  proper  consists  of  a  loose  network  of  connect- 
ive-tissue fibres,  which  contains  a  large  number  of  stellated 
pigmented  and  unpigmented  cells.  The  pigmented  cells  are 
more  numerous  in  the  outer  two-thirds  of  the  choroid,  their 
pigment  varying  considerably  in  tint  in  different  eyes.  In  al- 
binos it  may  be  wanting  or  it  is  slightly  yellowish,  in  negroes 
deep  brown,  or  even  black ;  and  all  intermediate  shades  may 
be  seen  in  different  eyes,  corresponding  in  a  general  way  with 
the  pigmentation  of  the  skin  and  hair  of  the  individual. 

In  this  loose  network  of  connective  tissue  lie  embedded  the 


ANATOMY. 


15 


innumerable  blood-vessels  of  the  choroid,  which  come  from 
the  short  posterior  ciliary  arteries.  The  veins  which  collect 
the  blood  and  empty  it  into  four  or  six  larger  trunks,  the  vencE 
vorticoscBj  lie  in  the  outer  two-thirds  of  the  choroid.  The  inner 
third  contains  the  capillaries  {chorio-capillaris).  (See  Fig.  9). 

The  choroid  contains,  moreovor,  a  large  number  of  nerves 
and  ganglionic  cells,  and  some  organic  muscular  fibres.  On 
its  inner  surface  it  is  lined  by  a  thin  elastic  hyaline  membrane 
•called  the  lamina  vitrea  of  the  choroid.  Upon  the  inner  side 
of  this  hyaline  membrane  lies  a  single  layer  of  large  hexago- 
nal cells,  containing  pigment  granules  in  the  whole  body  of 
the  cell.  This  is  the  pigmentary  epithelium  layer,  which 
formally  was  counted  as  a  part  of  the  choroid  and  later  as  a 
part  of  the  retina.     Its  cells  have   brush-like    offsets  on  their 


Fig.  10. — (After  Schultze).  Pigment  epithelium  cells  from  the  retina  of  man.  To 
the  left  a  view  from  their  exterior  surface.  The  other  cells  show  the  off- 
sets towards  the  retina  which  pass  in  between  the  rodes  and  cones. 


inner  surface  which  enter  between  the  outer  segments  of  the 
rods  of  the  retina,  withdrawing  under  the  influence  oftheHght 
and  getting  prolonged  during  rest  in  darkness.  The  retinal 
purple,  which  gives  the  outer  surface  of  the  retina  a  purpHsh 
tint  during  life,  is  exuded  by  this  layer,  which  is  therefore  to 
be  considered  as  a  special  glandular  organ  interposed  between 
the  choroid  and  retina.     (See  Fig.  10). 

Near  the  firm  attachment  of  the  uveal  tract  to  the  sclera,  at 
the  corneo-scleral  margin,  the  former  becomes  rapidly  thicker, 
and  thus  forms  the  ciliary  body  with  the  ciliary  processes  on 
its  inner  surface.  This  thickening  of  the  uveal  tract  is  espe- 
cially caused  by  the  presence  of  the  ciliary  muscle.  The  ten- 
don of  this  muscle,  by  its  insertion  into  the  corneo-scleral  tis- 
sue, forms  the  firm  attachment  between  the  uveal  tract  and  the 


16 


OPHTHALMOL  OCy. 


sclerotic.  The  fibres  of  this  muscle,  which  are  non-striated, 
spread  fan -like  backwards  and  a  little  inwards  in  the  ciliary 
body  and  are  finally  lost  in  the  choroid. 


Fig.  II. — Meridional  section  through  the  ciliary  body  of  a  very  short-sighted- 
(elongated)  eye.  The  fibres  of  the  ciliary  muscle  run  almost  all  in  a 
meridional  (longitudinal)  direction.     The  iris-angle  is  wide. 


There  are  two  apparently  distinct  sets  of  muscular  fibres,, 
the  one  lying  superficially  and  funning  in  a  longitudinal  (mer- 
idional) direction,  the  other  lying  more  deeply  and  running  in 
a  circular  (aequatorial)  direction.  The  former  kind  prevails  in 
elongated  (short-sighted)  eyes  (See  Fig.  ii),  while  the  latter 
kind  predominates  in  short  (far-sighted)  eyes.  (See  Fig.  12). 

The  ciliary  muscle  lies  embedded  in  the  outer  (more  super- 
ficial) part  of  the  ciliary  body.     Its  inner  surface  is  covered  by 


ANATOMY.  17 

the  tissue  proper  of  the  uveal  tract  with  its  vitreous  lamina. 
Upon  the  inner  side  of  the  latter  lies  the  thick,  dark  uveal 
layer,  the  continuation  of  the  pigmentary  epithelium  layer, 
and  further  on,  on  the  inner  side  of  this  lies  one  layer  of  cyl- 
indrical cells,  which  gradually  decrease  in  height  toward  the 
insertion  of  the  iris.  This  layer  is  considered  to  be  a  continu- 
ation of  the  retinal  tissue  and  is  called  the  ciliary  part  of  the 
retina  i^pars  ciliaris  rctince).     Since,  however,  the   ciliary  body 


Fig.  12. — Meridional  section  through  the  ciliary  body  of  a  very  far-sighted  (short) 
eyeball.  The  inner  fibres  of  the  ciliary  muscle  which  run  in  a  circular 
(aequatorial)  direction  are  very  numerous.     The  iris  angle  is  veiy  narrow. 

has  of  late  been  more  and  more  clearly  demonstrated  to  be 
the  organ  by  which  the  aqueous  humor  is  secreted,  and  has 
been  directly  called  the  gland  of  the  aqueous  humor,  it  may 
well  be  that  this  so-called  retinal  layer  had  better  be  consid- 
ered as  the  glandular  layer  of  the  ciliary  body. 

On  the  inner  surface  of  the  ciliary  body,  we  can  distinguish 


18  OPHTHALMOL  OGV. 

between  a  posterior,  smooth  part,  the  pars  non-plicata,  and  an 
anterior  wrinkled  part,  the  pars  plicata.  The  folds  and 
wrinkles  of  the  anterior  part  are  caused  by  small  irregular 
projections  called  the  ciliary  processes. 

These  processes,  about  seventy  in  number,  are  directed 
toward  the  axis  of  the  eye-ball,  and  form  a  circle  or  wreath 
upon  the  inner  surface  of  the  globe  behind  the  insertion  of  the 
iris. 

The  arterial  blood-vessels  of  the  ciliary  body  come  from  the 
anterior  ciliary  arteries,  which  reach  the  eyeball  with  the  recti 
muscles,  and  from  the  long  posterior  ciliary  arteries ;  the 
veins  carry  the  blood  back  partly  into  the  conjunctival  veins 
and  partly  into  the  venae  vorticosai. 


Fig.  13.— Pupillary  edge  of  the  iris.    Near  the  posterior  (uveal)  surface  the  fibres  of 
the  sphincter  pupillse  muscle  are  embedded. 

The  ciliary  nerves  form  a  coarse  network  on  the  inner  sur- 
face of  the  ciliary  muscle  and  send  small  branches  into  it  and 
to  the  iris. 

The  iris  is  inserted  into  the  ciliary  body  just  before  the  ten- 
don of  its  muscle  is  merged  in  the  corneo-scleral  tissue,  and 
the  plane  in  which  it  lies  forms  nearly  a  right  angle  with  the 
axis  of  the  eyeball.  It  forms  an  adjustable  diaphragm  across 
the  eyeball  and  is  pierced  by  a  central  opening,  the  pupil. 

The  bulk  of  the  tissue  of  the  iris  is  the  same  as  that  of  the 
ciliary  body.  This  tissue  is  in  the  main  a  very  loose  network 
of  fibres  and   cells,  and   contains    innumerable    blood-vessels. 


ANATOMY. 


19 


Near  its  anterior  and  posterior  surfaces,  it  becomes  more 
dense,  however,  and  consists  largely  of  spindle-shaped  cells. 
On  its  posterior  surface  it  has  the  darkly  pigmented,  thick, 
uveal  layer  and  on  its  anterior  surface  a  delicate  layer  of  endo- 
thelial cells.  The  anterior  surface  of  the  iris  is  uneven  on 
account  of  a  large  number  of  shallow  depressions  and  openings 
leading  into  crypts,  dipping  for  some  distance  down  into  the 
tissue,  and  of  wrinkles  produced  by  the  contraction  of  the  iris- 
tissue. 


Fig.  14. — (After  Leber).  Shows  the  manner  in  which  the  arterial  blood-supply  of 
the  eye  is  distributed  within  it  and  in  which  the  venous  blood  is  carried 
out  of  the  eye.    The  dark  vessels  are  the  veins. 


Near  the  pupillary  margin  and  nearer  the  posterior  surface 
of  the  iris,  we  find  embedded  in  the  iris  tissue  a  ring  of  organ- 
ic muscular  fibres,  the  sphincter  pupillce,  which,  by  its  contrac- 
tion, reduces  the  size  of  the  pupil.  (See  Fig.  13.)  Some 
authors  maintain,  also,  the    existence  of  an  antagonistic  mus- 


20 


OPHTHALMOL  OGY. 


cle,  which  is  said  to  lie  along  the  posterior  surface  of  the  iris 
and  to  run  in  a  radial  direction ;  it  is  called  the  dilator  muscle 
of  the  pupil.     I  have  never  seen  it  in  the  human  eye. 

The  arteries  of  the  iris  come  from  a  large  circular  blood- 
vessel, which  Hes  near  the  insertion  of  the  iris  into  the  ciliary 
body,  and  is  formed  by  the  anastomoses  of  the  anterior  ciliary 
arteries.  This  is  called  the  large  iris-circle.  From  this  arte- 
rial ring  branches  run  toward  the  pupil  in  a  radial  direction. 
After  having  formed  another  ring,  the  small  iris-circle^  and 
Just  before  reaching  the  sphincter  muscle  of  the  pupil,  they 
split  into  a  network  of  capillaries  which  are  distributed  between 
the  fibres  of  this  muscle.   (See  Fig.  14). 

The  veins  of  the  iris  run  back  to  the  ciliary  body,  and  finally 
empty  their  blood  into  the  venae  vorti'cosse. 

The  arteries  of  the  iris  have  a  much  thicker  muscular  coat 
than  any  other  arterial  blood-vessels  of  their  calibre  in  the  hu- 
man body. 

The  nerves  of  the  iris  come  from  the  ciliary  nerves. 


Fig.  15. — Longitudinal  section  through  the  entrance  of  the  optic  nerve  into  the  eye. 
The  lamina  cribrosa  is  not  drawn  in  order  to  better  show  the  manner  in 
which  the  medullated  optic  nerve  fibres  are  changed  into  non-medullated 
ones.  This  is  from  a  hypermetropic  eye;  in  a  myopic  eye,  the  line  of  tran- 
sition is  convex  forwards. 


§7.  The  Optic  nerve  when  it  reaches  the  sclerotic  is  enclosed 
in  three  sheaths.  The  outer  sheath  is  formed  by  the  dura  ma- 
ter  and  closely  applied  to  and  lining  this  is  the  arachnoid 
sheath.  These  two  sheaths  become  merged  in  the  sclerotic  at 
its  posterior    surface,  and  do    not  enter  the    eyeball.       The 


ANATOMY.  21 

third  or  inner  sheath  is  a  continuation  of  the  pia  mater 
of  the  brain.  It  encloses  the  nerve  directly,  and  also 
forms  the  network  of  connective  tissue  in  which  the  fibres 
of  the  optic  nerve  lie  embedded.  It  enters  the  globe  with  the 
nerve,  joins  the  inner  layers  of  the  sclerotic  and  ends  in  the 
lamina  cribrosa,  through  which  the  bundles  of  nerve-fibres 
pass  on  into  the  eyeball. 

Just  before  entering  the  lamina  cribrosa  the  optic  nerve  be- 
comes a  little  thinner,  and  its  nerve-fibres  lose  their  double 
contour.  As  soon  as  the  nerve-fibres  have  reached  the  inner 
surface  of  the  choroid,  they  bend  nearly  at  a  right  angle  with 
their  former  direction  and  expand  to  form  the  inner  (nerve- 
fibre)  layer  of  the  retina.  (See  Fig.  15). 

After  passing  through  the  sclerotic  and  choroid  (lamina  crib- 
rosa), and  before  entering  the  retina  proper,  the  nerve -fibres 
form  a  slight,  roundish  elevation  called  the  optic  papilla  or 
optic  disk.  Owing  to  the  manner  in  which  the  nerve-fibres 
thus  enter  the  eye  and  immediately  change  their  direction,  the 
normal  optic  papilla  shows  a  more  or  less  centrally  located, 
funnel  shaped  depression,  the  so-called  physiological  excava- 
tion. 

In  the  center  of  the  optic  nerve,  and  through  this  funnel- 
shaped  depression,  the  central  retinal  artery  and  vein  enter  the 
eyeball,  to  be  distributed  exclusively  in  the  retina. 

§8.  The  retina  is  separated  from  the  inner  surface  of  the 
choroid  by  the  pigmentary  epithelial  layer.  The  retina  proper 
reaches  forwards  to  the  ciliary  body,  where  it  ends  with  a 
scolloped  edge,  called  the  ora  serrata  of  the  retina. 

The  retina  is  the  light-perceiving  organ,  and  has  a  very 
complicated  structure.  If  we  do  not  count  the  pigmentary 
epithelial  layer,  it  consists  of  nine  distinct  layers. 

The  most  external  layer  is  that  of  the  rods  and  cones,  then 
follows  the  (doubtful)  external  limiting  membrane.  The  third 
layer  is  the  outer  granular  layer,  then  comes  the  outer  molecu- 
lar layer.  Then  follow  the  inner  granular  and  inner  molecular 
layers.  The  seventh  and  eighth  are  the  ganglionic  and  the 
nerve-fibre  layers,  and  these  are  separated  from  the  vitreous 
body  by  the  ninth  and  last  layer,  the  inner  limiting  membrane. 


22 


OPHTHALMOL  OGY. 


While  the  last  three  layers  are  called  the  brain-layers  of  the 
retina,  the  other  six  are  designated  as  its  neuro- epithelial  lay- 
ers.   (See  Fig.  i6). 


Fig.  1 6. — Schematic  representation  of  the  layers  of  the  retina.  (After  Merkel).  The 
inmost  layer  (downwards)  consists  of  optic  nerve  fibres  which  are  connected 
with  ganglionic  cells  (ganglionic  layer)  which,  in  turn,  send  their  offsets  into 
the  inner  molecular  layer  and  there  meet  with  the  fibres  coming  from  the 
cells  of  the  next  outer  layer,  the  inner  granular  layer.  These  cells  send 
fibres,  also,  outwards  into  the  outer  molecular  layer,  where  their  direct 
connection  with  fibres  coming  from  the  cones  has  been  proven.  The  cells 
forming  the  outer  granular  layer  also  send  fibres  into  the  outer  molecular 
layer  and  on  their  outer  side  are  connected  with  the  rods.  The  line  cut- 
ting the  bases  of  the  rods  and  cones  is  called  the  outer  limiting  membrane. 
The  inner  limiting  membrane,  dividing  the  retina  from  the  vitreous  body,  is 
not  seen  in  this  drawing. 


All   the  elements  of  which  the  the  retina  consists,  are   held 


ANATOMY. 


23 


together  and  in  position  by  supporting  connective-tissue  fibres, 
called  Mueller' s  fibres. 

While  a  direct  connection  between  the  optic  nerve-fibres 
and  the  cones,  within  the  retina,  has  been  anatomically  demon- 
strated, the  existence  of  such  a  connection  between  nerve- 
fibres  and  rods  has  so  far  not  been  shown.  The  retinal  purple 
gives  its  tint  only  to  the  outer  half  of  the  rods;  the  cones  are 
untinted. 

To  the  outer  side  of  the  optic  papilla  and  slightly  below  its 
horizontal  diameter  lies  the  yellow  spot  {macula  lutea),  the  point 
of  acute  vision.     (See  Fig.  17).    It  has  a  small  depression,  the 


Fig.  17. — (After  Helmholtz).  Section  through  the  macula  lutea  and  fovea  centralis  of 
the  retina.  Shows  that  in  this  part  of  the  retina  the  rods  disappear  and  the 
cones  stand  closer  together  and  are  longer  and  thinner  than  in  other  parts  of 
the  retina.  The  nerve  fibre  layer  ends  near  the  fovea  centralis.  The  gan- 
glionic cell- layer  is  considerably  thicker  m  the  periphery  of  ihe  macula 
lutea,  and  almost  disappears  in  the  fovea  centralis.  The  same  is  the  case 
with  the  outer  molecular  layer.  The  remaining  layers  are  so  thin  within 
the  fovea  centralis,  that  it  is  but  barely  possible  to  recognize  them. 

fovea  centralis,  excentrically  situated.  The  retinal  tissue  at  the 
periphery  of  the  yellow  spot  is  somewhat  thickened,  while  in 
the  fovea  centralis  it  is  exceedingly  thin.  Moreover,  in  the 
yellow  spot  the  cones  are  thinner  and  longer,  and  consequent- 
ly more  numerous  than  in  any  other  part  of  the  retina, 
and  the  rods  are  almost  altogether  wanting.  The  proportion 
between  the  rods  and  cones  grows  in  favor  of  the  former  from 
the  macula  lutea  to  the  ora  serrata.  These  two  facts  seem  to 
prove  that,  for  distinct  vision,  the  cones  are  of  much  greater 
importance  than  the  rods. 


24  ^  OPHTHALMOLOGY. 

The  blood-vessels  of  the  retina,  branches  of  the  central 
retinal  artery  and  vein,  lie  chiefly  in  the  nerve  fibre  and  gang- 
lionic layers,  but  sometimes  they  reach  even  into  the  inner 
molecular  layer.  The  outer  layers  have  no  blood-vessels 
and  receive  their  nutrition  from  the  chorio-capillaris.  In  the 
periphery  ot  the  retina  the  arteries  and  veins  unite  to  form 
terminal  loops. 

§9.  Behind  the  iris  lies  the  crystalline  lens,  a  transparent 
lentil-shaped  body.  It  consists  of  the  anterior  capsular  epi- 
thelium, and  of  the  so-called  lens-fibres  (elongated  epithelial 
cells),  and  is  inclosed  in  a  hyaline,  elastic  sack,  the  lens-capsule. 

The  part  of  the  lens-capsule  which  lies  anteriorly  to  the 
equator  of  the  lens  is  called  the  anterior  lens-capsule.  On  its 
inner  surface  lies  the  single  layer  of  cuboid  epithelial  cells,  the 
capsular  epithelium.  It  is  thicker  than  the  posterior  lens-cap- 
sule, which  is  devoid  of  epithelium. 


Fig.  18. — (After  J.  Arnold).     Anterior  surface  of  the  adult  crystalline  lens. 

The  lens-fibres  (or  lens-bands),  which  form  the  main  part  of 
its  structure,  are  also  epithelial  elements.  Where  their  ends 
join  each  other  beneath  the  lens-capsule,  they  form  sutures, 
which  are  seen  to  run  in  a  radial  direction  from  the  anterior 
and  posterior  poles  of  the  lens,  forming  angles  with  each  other 
of  about  120°.  On  the  anterior  surface  of  the  lens  two  of 
these  sutures  run  upwards  while  one  runs  downwards.  On  the 
posterior  surface  these  conditions  are  reversed.    (See  Fig.  18). 

The  crystalline  lens  is  suspended  from  the  ciliary  body  by 
the  zonule  of  Zinn,  or  suspensory  ligament.     This  consists    of 


ANATOMY.  25 

tough,  transparent  fibres,  which  come  from  the  vitreovs  body. 
While  on  their  way  forwards  they  are  bound  down  to  the  cili- 
ary body  and  follow  all  the  depressions  and  elevations  of  the 
ciliary  processes  until  they  reach  the  inner  anterior  angle  of 
the  ciliary  body.  From  here  they  bend  abruptly  inwards,  and 
partially  crossing  each  other  are  inserted  on  the  anterior  and 
posterior  lens- capsule,  a  short  distance  from  the  equator. 

In  the  normal  eyeball  the  pupillary  margin  of  the  iris  rests, 
and,  when  moving,  slides  upon  the  anterior  lens-capsule. 

§io.  The  space  between  the  posterior  surface  of  the  cornea, 
the  anterior  surface  of  the  iris,  and  the  central  portion  of  the 
anterior  lens-capsule,  is  called  the  anterior  chamber.  It  con- 
tains a  clear,  watery  fluid,  without  organized  elements,  the 
aqueous  humor. 

The  space  bound  by  the  peripheral  part  of  the  anterior  lens- 
capsule,  the  zonule  of  Zinn,  the  anterior  surface  of  the  ciliary 
body,  its  tendon,  and  the  posterior  surface  of  the  iris  is  called 
the  posterior  chamber.     It  also  contains  aqueous  humor. 

The  whole  space  backwards  from  the  lens  and  zonule  of 
Zinn  is  filled  with  a  transparent  gelatinous  substance,  the 
vitreous  body.  This  has  on  its  anterior  surface  a  depression, 
the  fossa  patellaris,  in  which  the  lens  lies.  In  the  region  of 
the  optic  disk  a  small  fissure  can  be  traced  in  the  vitreous 
body  from  behind  forward  towards  the  patellary  fossa,  called 
Stilling' s  canal;  the  hyaline  artery  lies  in  this  fissure  during 
embryonic  life.  The  vitreous  body,  especially  in  its  peripheral 
parts,  contains  a  moderate  number  of  wandering  cells. 

We  have  stated  above  that  the  sheaths  of  the  optic  nerve 
are  direct  continuations  of  the  meninges  of  the  brain.  The 
inter-vaginal  spaces  of  the  optic  nerve  are  in  fact  in  direct 
communication  with  the  intra-meningeal  spaces  in  the  cranium, 
and  can  be  injected  from  them. 

The  course  of  the  fluids  within  the  eyeball  is  at  present 
thought  to  be  from  behind  forwards  through  the  vitreous  body, 
the  zonule  of  Zinn,  and  the  posterior  chamber  into  the  an- 
terir  chamber;  and  the  exit  of  these  fluids  is  thought  to  take 
place  through  Fontana's  cavities  into  Schlemm's  canal  and  the 
lymphatics  and  veins  of  the  sclerotic  and  conjunctiva. 


26  OPHTHALMOL  OGY. 

There  are  direct  communications  between  the  supra-choroi- 
dal  space  and  Tenon's  space  where  the  venae  vorticosae  and 
the  ciHary  arteries  and  nerves  pierce  the  sclerotic,  and  fluids 
may  escape  by  these  channels  from  the  eyeball  into  Tenon's 
space. 

§11.  The  external  muscles  of  the  eyeball  are  six  in  number. 
Five  of  these,  the  four  recti  muscles  and  the  superior  ob- 
lique muscle,  together  with  the  levator  muscle  of  the  upper 
eyelid,  take  their  origin  from  the  apex  of  the  orbit  around  the 
canalis  opticus.  The  inferior  oblique  muscle  comes  from  the 
inner  margin  of  the  lachrymal  canal. 

§12.  The  lachrymal  apparatus  consists  of  the  lachrymal 
gland,  the  puncta  lachrymalia,  the  canaliculi  lachrymales,  the 
lachrymal  sack,  and  the  nasal  duct. 


Fig.  19. — (After  Gerlach).  Shows  the  direction  in  which  the  lachrymal  canaliculi 
run  while  passing  from  the  lachrymal  papillae  through  the  eyelids  to  the 
lachrymal  sack. 

The  puncta  lachrymalia,  as  stated  above,  lie  near  the  inner 
angle  of  the  palpebral  fissure  at  the  apex  of  the  lachrymal 
papillce,  and  are  the  external  orifies  of  the  lachrymal  canal- 
iculi. The  latter,  after  having  run  into  the  lid  for  a  little  dis- 
tance at  a  right  angle  to  the  lid  margin,  turn  abruptly 
towards  the  nose  and  converge  towards  the  lachrymal  sack. 
(See  Fig.  19).     Just  before  reaching  the  latter  they  unite  into 


ANATOMY.  27 

one  short  canal.  The  lachrymal  sack  forms  an  oblong  recep- 
tacle for  the  tears  lying  behind  the  ligamentum  palpebrale  in- 
ternum. Its  upper  portion  {cupola^  lies  higher  than  the  entrance 
of  the  canaliculi.  The  lachrymal  sack  is  about  twelve  milli- 
meters long,  and  ends  below  in  the  nasal  lachrymal  duct.  The 
latter  opens  upon  the  mucous  membrane  of  the  inferior  nasal 
meatus,  just  under  the  insertion  of  the  inferior  turbinated  bone. 

The  lachrymal  sack  is  surrounded  by  bone  at  its  posterior 
surface  only,  the  nasal  duct  is  enclosed  in  bone,  except  at  its 
nasal  extremity.  Here  the  duct  pierces  the  mucous  membrane 
obliquely.  Its  orifice  forms  a  long  oval  slit.  The  length  of 
the  duct  is  about  15  to  20  millimeters. 

The  lachrymal  gland,  which  secretes  the  tears,  is  divided 
into  two  portions,  an  upper,  larger,  and  a  lower,  very  much 
smaller  one.  The  upper  portion  enclosed  in  its  tough  capsule, 
lies  in  the  lachrymal  fossa  of  the  frontal  bone,  just  behind  the 
upper  outer  margin  of  the  orbit.  The  lower  portion,  which 
consists  only  of  a  few  loosely  connected  acini,  rests  upon  the 
fornix  of  the  conjunctiva,  just  below  the  upper  one.  Small 
ducts  lead  the  tear-fluid  into  the  conjunctival  sack,  whence 
it  flows  into  the  nose  through  the  lachrymal  puncta,  and  the 
remainder  of  the  drainage  part  of  the  lachrymal  apparatus. 
Around  the  base  of  the  lachrymal  papillae  lies  a  minute 
muscle — Horner's  muscle — whose  function  it  is  to  assist  in  suck- 
ing up  the  tear-fluid. 

3.  The  blood  supply  of  the  optical  apparatus  comes  from 
the  branches  of  both  carotids.  The  external  carotid  reaches 
the  eye  from  the  surface.  The  ophthalmic  artery,  coming 
from  the  internal  carotid,  enters  the  orbit  with  the  optic 
nerve,  lying  beneath  it  within  the  optic  canal.  Here  it  gives 
off  small  branches  running  to  the  nerve  and  its  sheaths. 
Within  the  orbit  the  ophthalmic  artery  lies  first  on  the  tem- 
poral side  of  the  nerve,  then  it  rises  and  passes  between  the 
optic  nerve  and  the  superior  rectus  muscle  towards  the  inner 
wall  of  the  orbit,  where  it  forms  the  posterior  and  anterior 
ethmoidal  arteries.  During  this  passage  it  gives  off  the  follow- 
ing larger  branches,  the  lachrymal  artery,  the  supraorbital  ar- 
tery, the  posterior  ethmoidal,  and  the  naso-frontal  artery. 


28  OPHTHALMOL  OGV. 

The  lachrymal  artery  lies  on  the  temporal  side,  passes 
forward  between  the  rectus  superior  and  rectus  externus  to  the 
lachrymal  gland,  and  thence  to  the  eyelid  and  forms  the  later- 
al superior  and  inferior  palpebral  arteries  which  anostomose 
with  the  naso-frontal.  The  supraorbital  artery  passes  forward 
with  the  nerve  of  the  same  name  under  the  roof  the  orbit  and 
by  way  of  the  supraorbital  incision  reaches  the  forehead. 
The  naso-frontal  artery  passes  forward  on  the  nasal  side  of 
the  orbit  and  after  having  left  the  orbit  spreads  in  the  neigh- 
boring tissues.  During  their  passage  through  the  orbit  all 
of  these  blood-vessels  give  off  small  branches  for  the  muscles 
of  the  orbit,  the  orbital  fat  and  connective  tissue.  (See  Fig.  20). 


Fig.  20. — (After  Merkel).     Left  orbit  uncovered  from  above  to  show  the  distribution 
of  the  arterial  blood-supply  in  the  orbit,  eyeball  and  neighboring  parts. 

The  anterior  ciliary  arteries  come  from  such  muscular 
branches  in  the  four  recti  muscles.  The  posterior  ciliary 
arteries  come  either  directly  from  the  ophthalmic  artery,  or 
from  its  larger  branches,  soon  after  they  have  left  the  ophthal- 
mic artery.  There  are  usually  six  larger  ciliary  arteries 
which  divide  each  into  three  or  more  branches  and  pass 
forward  to  the  eyeball  which  they  enter  around  the  entrance 
of  the  optic  nerve.  According  to  their  manner  of  spreading  in 
the  interior  of  the  eye,  they  are  then  called  short  or  long  pos- 
terior ciliary  arteries.     The  central  retinal  artery  comes  either 


ANATOMY.  29 

as  a  separate  branch  directly  from  the  ophthalmic  artery  or 
from  one  of  its  larger  branches,  enters  the  optic  nerve  near 
the  eyeball  in  an  oblique  direction  and  with  it  reaches  the 
retina.  The  infraorbital  artery  passes  with  the  nerve  of  the 
same  name  through  the  infraorbital  canal  to  the  surface  and 
running  forward  through  this  passage  reaches  the  lower  eyelid. 

All  orbital  arteries  are  very  tortuous  and  thus  the  move- 
ments of  the  eyeball  do  not  interfere  with  the  blood  flow. 

The  finer  veins  of  the  orbit  follow  in  a  general  way  the 
course  of  the  arteries.  The  superior  ophthalmic  vein  collects 
the  blood  from  the  lids,  forehead  and  lachrymal  apparatus, 
furthermore  from  the  ethmoidal  veins,  a  number  of  muscular 
and  ciliary  veins  and  the  central  retinal  vein.  It  passes  out  of 
the  orbit  by  the  superior  orbital  fissure,  and  empties  into  the 
cavernous  sinus.  The  lower  ophthalmic  vein  collects  the  blood 
from  a  number  of  muscular  veins,  the  ciliary  veins,  and,  also 
going  through  the  upper  orbital  fissure  either  joins  the  super- 
ior ophthalmic  vein  or  enters  the  cavernous  sinus  separately. 

The  veins  of  the  eyelid  form  near  the  inner  canthus  the 
angular  vein  which  joins  the  anterior  facial  vein,  and  near  the 
outer  canthus  the  temporal  and  facial  veins. 

§14.  Aside  from  the  optic  nerve,  the  orbital  cavity  contains 
a  large  number  of  smaller  nerves.  They  enter  the  orbit 
through  the  superior  orbital  fissure.  The  trochlear  nerve 
passes  forward  with  and  spreads  within  the  superior  oblique 
muscle.  The  abducens  nerve  goes  to  the  external  rectus 
muscle.  The  oculomotor  nerve,  soon  after  having  entered  the 
orbit,  is  divided  into  two  branches.  The  upper  and  thinner  one 
forms  a  branch  for  the  superior  rectus,  and  one  for  the  levator 
muscle  of  the  upper  lid.  The  lower  and  thicker  branch  is 
again  split  into  three  branches  for  the  internal  and  inferior  rec- 
tus and  the  inferior  oblique  muscles,  respectively.  The  last 
named  branch  forms  the  short  root  of  the  ciliary  ganglion. 
The  ophthalmic  nerve,  which  takes  its  origin  from  the  fifth 
(trigeminus)  nerve  forms  three  branches  within  the  orbit,  the 
supraorbital,  lachrymal,  and  naso-ciliary  nerves.  The  supra- 
orbital nerve  runs  forward  under  the  roof  of  the  orbit,  lying  on 
top  of  the  orbital  fat  (with  the  artery  of  th^  same  name),  and 


30  OPHTHALMOLOGY. 

splits  in  two  branches  of  which  one  retains  the  name,  the  other 
is  called  the  frontal  branch.  The  lachrymal  nerve  goes  to  the 
lachrymal  gland.  The  naso-ciliary  nerve  forms  the  long  root 
for  the  ciliary  ganglion  and  then  passing  to  the  nasal  side  of 
the  orbit  gives  off  two  or  three  long  ciliary  nerves  and  ends  in 
two  branches,  the  infratrochlear  nerve  and  the  ethmoidal 
nerve,  which  leaves  the  orbit  through  the  foramen  ethmoidale 
anterius. 

The  ciliary  ganglion  consists  of  motor,  sensory  and  sympa- 
thetic fibres.  The  motor  fibres  reach  it  by  the  short  root 
formed  by  the  branch  of  the  oculomotor  nerve  for  the  inferior 
oblique  muscle.  The  sensory  fibres  come  from  the  naso-ciliary 
branch  of  the  ophthalmic  nerve  (trigeminus)  and  from  its 
long  root.  The  sympathetic  fibres  come  from  the  plexus  of 
the  cerebral  carotid  and  join  the  long  root  of  the  ciliary  gang- 
lion. From  this  ganglion  spring  the  short  ciliary  nerves  (from 
2  to  6)  which  divide  into  about  twenty  smaller  branches,  and 
enter  the  eyeball  in  a  circle  around  the  optic  nerve  entrance 
together  with  the  long  ciliary  nerves  from  the  naso- ciliary 
nerve. 


CHAPTER  II.— METHODS  OF  EXAMINING  THE  EYE. 

§15.  For  all  examinations  of  the  eye  good  light  is  absolute- 
ly required.  In  day-time  it  is  therefore  best  to  see  the  pa- 
tient near  a  window  and  opposite  to  it,  avoiding,  however, 
bright  sunlight.  After  the  patient  has  been  properly  seated, 
a  systematical  examination  should  begin  with  the  inspection 
of  the  cutaneous  surface  of  the  eyelids.  Then  the  eyelashes 
and  their  position,  the  orifices  of  the  Meibomian  glands,  the 
motility  of  the  eyelids,  and  the  size  of  the  palpebral  fissure 
should  be  carefully  noted.  To  get  a  good  view  of  the  outer 
and  inner  canthus,  the  puncta  lachrymalia  and  the  caruncula 
lachrymalis,  it  is  best  to  slightly  raise  the  upper  eyelid  with 
the  forefinger,  while  the  thumb  of  the  same  hand  gently  pulls 
down  the  lower  lid.  This  little  manipulation,  which  has  to  be 
used  very  frequently  in  examining  eyes,  should  be  executed 
without  exerting  the  slightest  pressure  on  the  eyeball.  If  it 
is  impossible  to  make  a  perfect  inspection  with  the  aid  of  this 
manipulation,  it  will  be  best  to  draw  the  upper  eyelid  upward 
with  the  thumb  of  one  hand  and  the  lower  eyelid  downward 
with  the  thumb  of  the  other  hand.  If  the  skin  of  the  lower 
eyelid  is  too  slippery  for  this  manoeuvre,  a  towel  or  piece  of 
linen  cloth  wound  around  the  thumb  will  be  of  great  assist- 
ance. In  thus  separating  the  eyelids  all  pressure  upon  the 
eyeball  must  be  carefully  avoided.  This  is  most  surely  accom- 
plished by  laying  the  thumbs  on  the  skin  of  the  eyelids  near 
the  orbital  margins  and  drawing  them  apart  by  dragging  on 
the  skin  only. 

If  there  is  any  complaint  about  stillicidium  lachrymarum 
(tear-dropping,  lachrymation),  the  first  point  to  be  examined 
into,  is,  whether  the  puncta  lachrymalia  lie  in  contact  with  the 
ocular  conjunctiva  near  the  caruncle.  Then  making  pressure  on 
the  lachrymal  sack,  while  the  puncta  lachrymalia  are  closely 
watched,  the  escape  of  fluid   into  the   conjunctival   sack  will 

—31— 


32  OPHTHALMOL  OGY. 

give  US  an  indication  of  any  obstruction  to  the  proper  drainage 
of  the  tears  into  the  nose. 

If  there  is  an  escape  of  fluid  from  either  punctum,  its  char- 
acter, whether  watery,  mucous  or  purulent,  will  be  of  import- 
ance with  regard  to  the  diagnosis  of  an  inflammatory  process 
in  the  lachrymal  sack.  The  further  exploration  of  the  lach- 
rymal sack  and  duct  by  means  of  probes  will  be  detailed  in 
Chapter  IV. 

To  inspect  the  ocular  conjunctiva  we  draw  the  lids  apart  in 
the  manner  just  described,  and  notice  whether  there  is  any 
abnormal  condition.  If  there  is  hypersemia,  we  should  make 
sure  whether  this  hyperaemia  is  confined  to  the  conjunctival 
blood-vessels,  or  whether  it  involves  also  the  ciliary  blood- 
vessels in  the  sclerotic  near  the  cornea-scleral  margin.  This 
is  best  done  by  sliding  the  conjunctiva  slightly  upon  the  scle- 
rotic by  means  of  the  eye-lids.  A  hyperaemia  confined  to  the 
moveable  tissues  concerns  the  conjunctival  blood-vessels  only. 
These  vessels  are,  moreover,  comparatively  large  and  convo- 
luted, and  are  easily  distinguishable  as  separate  vessels,  where- 
as the  deeper-lying  ciliary  vessels  are  much  finer  and  appear 
rather  as  a  ring  of  diffuse  redness  with  a  bluish  tint,  densest 
next  to  the  cornea  and  shading  off  into  the  sclerotic. 

If  the  symptoms  complained  of  refer  to  the  conjunctiva  of 
the  eyelids,  or  if  a  foreign  body  has  entered  the  conjunctival 
sack,  we  must  next  inspect  the  inner  surface  of  the  eyelids.  The 
conjunctival  surface  of  the  lower  eyelid  and  the  lower  fornix 
of  the  conjunctiva  are  easily  exposed  to  view  by  directing  the 
patient  to  look  upward  and  drawing  the  skin  of  the  lower  eye- 
lid downward  toward  the  cheek  with  the  thumb.  In  deeply 
set  eyes,  the  lower  fornix  is  most  perfectly  exposed  by  draw- 
ing the  lower  lid  downwards,  while  the  patient  also  looks  down- 
wards {Arlt.)  The  exploration  of  the  conjunctival  surface  of 
the  upper  eyelid  and  the  upper  fornix  of  the  conjunctiva  re- 
quires more  skill,  and  is  accomplished  in  the  following  way : 
Place  the  thumb  of  the  right  hand  (when  examining  the  pa- 
tient's left  eye)  against  the  orbital  margin  above  the  outer  an- 
gle of  the  palpebral  fissure,  then  take  hold  of  the  cilia  with 
the  thumb  and  forefinger  of  the  left  hand  and  direct  the  pa- 
tient to  look  downwards.     Next  draw  the  eyelid,  thus  held  by 


METHODS  OF  EXAMINATION.  33 

the  cilia,  gently  downwards  and  forwards,  at  the  same  time 
shifting  the  thumb  of  the  right  hand  into  the  depression, 
which  appears  between  the  eyebrow  and  the  tarsus,  and  lastly 
turn  the  lid-margin  upwards,  using  the  right  thumb  to  keep 
the  upper  edge  of  the  tarsus  in  position,  while  the  whole  tar- 
sus is  being  turned  around  its  upper  edge  as  a  fixed  center. 
Instead  of  the  thumb  a  smaller  round  object  (such  as  a  probe, 
a  pencil,  or  a  match),  may  be  used  to  fix  the  upper  edge  of 
the  tarsus.  Examining  the  patient's  right  eye,  the  hands 
should  be  reversed.  When  the  eyeHds  are  very  forcibly  shut 
and  the  patient  is  unable  to  assist  in  looking  down,  or  when 
the  conjunctival  sack  is  considerably  shrunken,  it  may  be  very- 
difficult  to  bring  the  conjunctival  surface  of  the  upper  lids  to 
view.  When  the  eye-lashes  are  absent,  it  is  often  sufficient  to 
direct  the  patient  to  look  strongly  downward,  to  lay  the  end 
of  a  probe  along  the  upper  edge  of  the  tarsus  so  as  to  press  it 
gently  downwards  and  backwards,  and  to  draw  the  lid  margin 
upwards  by  means  of  the  ball  of  the  thumb  appHed  to  the  dry 
skin  of  the  eyelid  near  its  free  margin  [Desmarres).  In  this, 
as  in  the  following  manipulations,  we  will  be  materially  aided 
by  first  instilling  one  or  more  drops  of  a  4%  solution  of  mu- 
riate of  cocaine  into  the  conjunctival  sack. 

In  young  children  the  inspection  of  the  Hds,  as  well  as  of 
the  eyeball,  is  best  affected  by  taking  the  child's  head  in  the 
lap,  or,  if  necessary,  between  the  knees,  while  its  legs  rest  on 
the  lap  of  another  person.  Sometimes  a  general  anaesthetic 
may  be  necessary. 

When  the  lids  and  conjunctiva  have  thus  been  explored,  we 
next  inspect  the  cornea.  A  healthy  cornea  is  perfectly  trans- 
parent and  polished,  and  reflects  the  light  like  a  mirror.  These 
two  peculiarities  allow  us  to  distinguish  all  affections  of  this 
membrane  easily. 

If  there  is  any  form  of  inflammation,  or  an  abrasion,  a  scar, 
or  a  foreign  body  present,  the  tissue  of  the  cornea  will  be  seen 
more  or  less  affected,  either  in  its  transparency,  or  in  the  per- 
fection of  polish  of  its  surface.  Any  considerable  changes  in 
the  curvature  of  the  surface  of  the  cornea  will  be  easily  de- 
tected by  putting  the  patient  in  such  a  position  that  we  can 
see  the  reflected  image  of  a  window  or  a  flame  on  the  cornea. 


34  OPHTHALMOLOG  V. 

By  then  directing  the  patient  to  move  his  eye,  say  in  a  hori- 
zontal direction,  so  as  to  allow  the  reflected  image  to  move, 
so  to  speek,  over  the  cornea,  it  will  become  distorted  as  soon 
as  it  reaches  the  part  in  which  the  curvature  is  altered.  When 
the  injury  is  so  small  that  we  can  barely  find  it,  staining  with  a 
solution  of  fluorescein,  lO  grains  to  the  ounce,  is  of  great 
value.  While  the  normal  portion  of  the  tissue  remains  un- 
colored,  the  parts  denuded  from  epithelium  take  on  a  green 
tint. 

The  sensibility  of  the  cornea  is  examined  by  touching 
it  with  a  camel's  hair  brush  or  a  small  roll  of  tissue  paper. 

After  examining  the  cornea,  we  inspect  the  contents  of  the 
anterior  chamber,  the  aqueous  humor,  which,  in  the  normal 
condition,  is  also  perfectly  transparent.  Any  lack  of  trans- 
parency in  this  fluid,  is  due  to  an  affection  of  the  deeper  por- 
tions of  the  eyeball. 

In  examining  the  iris,  we  have  first  to  pay  attention  to  any 
anatomical  changes  in  its  tissue,  and  then  to  its  function  as  a 
moveable  diaphragm.  The  pupil  ought  to  expand  promptly 
on  shading  the  eye,  and  to  contract  promptly  on  exposing  the 
eye  again  to  the  light. 

If  the  iris  is  inflamed,  there  is  hyperaemia  of  both  the  con- 
junctival and  ciliary  blood-vessels.  The  latter  show  as  a  pink 
or  bluish-red  zone  around  the  corneo-scleral  margin  and  are 
not  moveable  with  the  conjunctiva.  The  tissue  of  the  iris  ap- 
pears swollen  and  loses  its  lustre.  The  color  of  the  iris  is 
also  changed,  in  blue  eyes  taking  on  a  greenish  shade,  in  dark 
eyes  a  dirty  brown.  After  iritis  has  become  established,  the 
pupil  is  nearly  or  wholly  immoveable. 

The  motility  of  the  pupil  may  also  be  disturbed  when  there 
are  no  inflammatory  symptoms  present.  In  order  to  test  this, 
we  cover  the  healthy  eye  so  as  to  exclude  all  light  from  it,  and 
then,  alternately  shading  the  other  eye  with  the  hand  and  ex- 
posing it  to  light  again,  we  watch  the  size  of  the  pupil.  While 
this  examination  goes  on,  the  patient  must  keep  his  eyelids 
well  apart  and  look  steadily  in  the  same  direction.  If  the  pu- 
pil remains  unchanged,  under  the  influence  of  alternate  light 
and  shade,  we  must  see  whether  it  contracts,  perhaps,  during 
the  effort  to  accommodate  for  a  near  object. 


METHODS  OF  EXAMINATION,  35 

We  should,  furthermore,  see,  whether  the  iris  trembles  when 
the  eyeball  is  moved.  The  size  and  shape  of  the  pupil,  when 
at  rest,  are  also  to  be  noted. 

The  position  of  the  plane  of  the  iris  is  also  of  importance. 
We  must  see,  whether  its  periphery  is  bulged  forwards  or 
drawn  backwards,  or  whether  any  particular  part  of  it  is  pro- 
truding, etc. 

If  the  pupil  is  immoveable,  or  acts  imperfectly,  it  is  best  to 
test  its  dilatability  by  the  instillation  of  a  mydriatic.  The  sim- 
plest one  for  a  mere  examination  is  a  one  per  cent,  solution  of 
homatropinum  hydrobromatum,  as  its  action  disappears  very 
readily  (in  from  8  to  12  hours).  If  a  stronger  mydriatic  is 
needed,  as  is  generally  the  case  in  inflammation  of  the  iris,  a 
one  per  cent,  solution  of  atropinum  sulfuricum  should  be  used 
in  its  place. 

An  inflammatory  process  of  the  ciliary  body  is  recognized 
by  a  deep  bluish-red  zone  of  injection  around  the  corneo- 
scleral margin,  and  by  pain  on  pressure  upon  the  ciliary  re- 
gion. The  latter  symptom  is  easily  ascertained,  by  pressing 
slightly  upon  the  ciliary  region  through  the  closed  eyelids 
with  a  pencil  or  any  rounded  small  object,  or  even  with  the 
finger.  (Tenderness  of  the  ciliary  region  on  pressure  may 
also  be  present  in  iritis). 

Inspecting  the  crystalline  lens,  we  have  chiefly  to  notice  the 
transparency  of  its  capsule,  cortex  and  nucleus.  In  order  to 
see  the  equatorial  portions  of  the  lens  the  pupil  must  be  wide- 
ly dilated.  If  the  lens  is  wanting,  or  is  dislocated,  from  the 
patellary  fossa,  the  iris  will  tremble  (irido  done  sis),  except  when 
the  whole  lens  lies  in  the  anterior  chamber,  a  condition 
which  presents  otherwise  characteristic  appearances.  See 
Chapter  XV. 

If  the  lens  is  transparent  enough,  we  may  also  be  able  to 
see  a  cyclitic  membrane,  changes  in  the  anterior  portion  of  the 
vitreous  body,  a  detached  retina,  or  an  intra-ocular  tumor 
through  it.  For  the  examination  of  the  anterior  third  of  the 
eyeball,  we  make  use  of  the  ^o-zd^^^di  focal  or  oblique  illumina- 
tion, which  enables  us  to  detect,  for  instance,  slight  changes  in 
the  cornea  or  lens,  which  in  the  diffuse  illumination  may  escape 
our  notice  altogether.     The  patient  is  seated  opposite  the  ex- 


36  OPHTHALMOLOGY. 

aminer  and  a  lamp  is  placed  at  the  side  and  somewhat  in  front 
of  the  eye  under  examination,  a  convex  lens  of  two  and  a 
half  or  three  inches  focus,  is  used  to  throw  a  pencil  of  light 
obliquely  upon  the  parts  under  examination.  By  moving  this 
lens  nearer  to  or  farther  from  the  eye  the  focus  may  be  thrown 
upon  deeper  or  more  superficial  parts.  It  is  sometimes  a  de- 
cided help  in  making  a  diagnosis  to  view  the  parts  thus  illumi-  * 
nated  with  a  magnifying  lens  held  in  the  other  hand.  (See 
Fig.  21). 


Fig.  21. — (After  Meyer).     Focal  or  oblique  illumination  of  the  anterior  parts  of  the 
eyeball. 

Tumors,  abscesses,  etc.,  within  the  orbit  may  be  detected  by 
the  protrusion  and  displacement  of  the  eyeball  and  can  often 
be  located  by  palpation. 

§i6.  Thus  far,  we  have  treated  of  the  visible  changes  oc- 
curring in  affections  of  the  anterior  part  of  the  eyeball  only. 
Eye  affections,  not  accompanied  by  changes,  visible  to  the 
naked  eye,  call  for  the  testing  of  vision  subjectively. 

The  acuteness  of  visioJt  is  tested  by  means  of  test-types^ 
and  when  it  is  very  much  reduced,  by  the  outstretched  fingers 
of  one  hand.  The  test-types  in  use  are  constructed  in  such  a 
manner  that  their  limbs  are  seen  by  the  normal  eye  under  a 
visual  angle  of  one  minute,  while  the  whole  letter  is  seen  un- 
der an  an  angle  of  five  minutes.  Of  these  letters  one  set  is 
used  for  distant  vision  and  contains  letters  to  be  seen  by  the 
normal  eye  distinctly  at  from  200  to  20  or  less  feet  distance. 
The  other  set  is  constructed  for  near  vision.  The  acuteness 
of  vision  is  expressed  in  the  form  of  a  fraction,  the  denomi- 
nator of  which  gives  the  distance  at  which  the  letters  ought 
to  be  recognized,  while  the  numerator  gives  the  distance  at 
which  they  are  actually  seen.  The  normal  eye  must  see  the 
letters  called  XX,  in  our  set  of  test-types,  at  20  feet,  and  this 


METHODS  OF  EXAMINATION,  37 

is  noted  in  the  following  way,  V  (visus)='7xx.  If  the  patient 
sees  the  letters,  which  the  normal  eye  recognizes  at  lOO  feet, 
at  20  feet  only,  we  write  V  =^°/c,  and  his  visual  acuteness  is 
said  to  be  only  one-fifth  of  that  of  a  normal  eye.  In  making 
such  examinations  the  test-types  must  be  well  lighted  and  the 
patient  must  sit  or  stand  with  his  back  to  the  light. 

When  no  letters  can  be  distinguished,  we  may  examine  the 
acuteness  of  vision  by  means  of  the  outstretched  fingers.  In 
doing  so,  we  should  be  careful  to  hold  the  fingers  against  a 
dark  back-ground  and  move  from  the  distance  towards  the  pa- 
tient until  he  can  count  them. 

§17.  The  whole  region  within  which  an  eye,  when  perfectly 
at  rest,  can  perceive  objects,  is  called  its  visual  field.  The  ex- 
amination of  the  visual  field  is  best  made  by  an  instrument, 
called  perimeter,  of  which  a  number  of  patterns  are  in  use, 
consisting  of  an  half  or  quarter  arc  which  can  be  moved  in  the 
directions  of  all  the  meridians.  A  white  or  colored  object  is 
slid  along  this  arc  from  the  periphery  towards  the  center,  and 
the  patient  who  fixes  the  center  announces  when  he  sees  this 
object.  The  field  can  then  be  drawn  on  forms  printed  for  the 
purpose.  (See  Fig.  22).  It  can  also  be  directly  projected  on 
a  plane  surface  (black-board)  and  thus  be  accurately  mapped 
out.  The  simplest  method  is,  to  let  the  patient  cover  one  eye 
and  to  direct  him  to  gaze  steadily,  with  the  other  one  into  the 
observer's  opposite  eye.  Then  move  the  fingers,  or  a  small 
staff  with  a  white  tip,  from  different  directions  towards  the  line 
connecting  his  eye  with  that  of  the  observer,  keeping  always 
at  an  equal  distance  from  both,  and  notice  when  he  first  rec- 
ognizes it.  If  your  own  eye  is  normal  and  gazes  steadily  Into 
the  patient's  eye  during  this  procedure,  the  extent  of  your  own 
visual  field  will  allow  you  to  notice  at  once  any  defect  in  his. 

If  the  patient's  sight  is  so  poor,  that  he  can  no  longer  recog- 
nize the  fingers,  or  other  small  objects,  as  in  a  case  of  cata- 
ract, the  visual  field  is  best  examined  with  a  candle-flame  in  a 
dark  room.  This  is  done  exactly  in  the  same  way,  directing 
the  patient  to  look  straight  ahead  and  not  to  change  the  posi- 
tion of  his  eye  and  moving  the  candle  towards  the  visual  line 
in  the    direction  of  the  different   meridians.     Care  should  be 


38  OPHTHALMOLOGY. 

taken  to  shade  the  patient's  eye  whenever  the  direction  of  the 
candle  is  changed. 


Fig.  22.— (After  Landolt).  Outlines  of  the  visual  field  of  the  right  eye  for  white 
blue,  red  and  green,  showing  at  the  same  time  the  manner  in  which  the 
outlines  of  a  pathologically  changed  visual  field  can  be  mapped  out. 

§i8.  The  light- sense  is  best  examined  by  Foerster's  photo- 
meter, an  instrument  in  which  the  light  of  a  candle  (of  one 
candle-power)  illuminates  stripes  of  black  and  white  on  the 
the  opposite  wall  of  a  blackened  box,  into  which  the  patient 
looks.  The  size  of  the  window  through  which  the  light  is 
admitted  can  be  changed  at  will  and  thus  the  lowest  amount 
of  light  which  allows  of  a  differentiation  between  the  white 
and  black  stripes  in  a  given  case  can  be  easily  found.  By 
then  comparing  the  result  with  that  of  an  eye  of  a  normal 
power  of  differentiation  we  are  enabled  to  tell  whether  the 
patient's  light- sense  is  normal  or  diminished. 

§19.     Sometimes  we  have  to  examine  a  patient  in  regard  to 


METHODS  OF  EXAMINATION.  39 

his  perception  of  colors.  A  great  many  methods  for  this  pur- 
pose have  of  late  come  into  use,  since  the  subject  of  color- 
blindness has  received  special  attention  in  connection  with  the 
marine  and  railroad  service  of  almost  all  civilized  countries. 
Holmgren's  method,  in  which  .skeins  of  variously  colored 
wool  are  employed,  is  the  most  convenient.  The  patient  is 
first  shown  a  light  green  skein  and  asked  to  match  it  with  simi- 
lar tints.  If  he  is  color-blind,  he  will  make  strange  mistakes, 
selecting  gray-green,  brown,  yellowish,  pink  and  grayish  red, 
etc.     For  further  details,  see  chapter  XXIV. 

§20.  The  ifitra-ocular  tension  is  best  examined  by  directing 
the  patient  to  look  down,  and  and  then  gently  laying  the  tips 
of  both  index  fingers  upon  the  upper  lid,  and  alternately  press- 
ing them  upon  the  globe,  as  we  are  accustomed  to  do  in 
searching  for  fluctuation.  We  determine  in  a  general  way, 
whether  an  eye  is  harder  or  softer  than  normal,  by  comparing 
it  with  its  fellow.  When  both  eyes  are  affected,  the  tension 
should  be  compared  with  that  of  the  healthly  eyes  of  another 
person,  unless  the  examiner  is  expert  enough  to  judge  acur- 
ately  without  such  comparison. 

§21.  The  accommodative  power  of  an  eye  is  examined  by 
directing  the  patient  to  look  at  a  small  object  (finest  test- 
types)  and  moving  it  so  close  to  the  eye  that  he  can  but  just 
recognize  it.  If  the  accommodation  is  defective  this  near- 
point  {punctum  proximum),  will  be  farther  from  the  eye  than  it 
should  be,  taking  into  account  the  age  of  the  patient.  (See 
Chapter  XX). 

This  examination  will  at  the  same  time  give  us  a  hint  with  re- 
gard to  the  state  of  refraction  of  the  examined  eye.  If  it  can 
read  finest  print  for  a  prolonged  period  and  at  a  smaller  dis- 
tance from  the  eye  than  the  age  of  the  patient  would  warrant, 
the  eye  is  short-sighted.  If  it  is  unable  to  read  the  smallest 
print  at  all  or  for  any  length  of  time,  at  the  normal  distance  it 
is  probably  far-sighted  or  astigmatic. 

§22.  In  order  to  see  any  changes  in  the  conditions  of  the 
posterior  portions  of  the  eye,  of  the  vitreous  body,  the  optic 
nerve,  the  retina  and  the  choroid,  we  have  to  make  use  of  the 
ophthalmoscope. 


40  OPHTHALMOLOG  V, 

Light  thrown  into  an  eye  will  not  only  be  preceived  there, 
but  it  is  also  reflected.  The  reflected  rays  return  to  the 
source  of  light  by  the  same  way  by  which  they  have  entered 
the  eye. 

When  the  pupil  of  an  examined  eye  is  very  large  the  ob- 
server's unaided  eye  is  sometimes  able  to  catch  such  rays  re- 
turning to  their  source,  and  then  he  sees  the  usually  black  pupil 
appearing  shining  red.  In  this  way,  of  course,  no  details  of 
the  background  of  the  eye  are  to  be  distinguished.  To  make 
this  possible  it  is  necessary  to  bring  the  observer's  eye  into  the 
axis  of  the  returning  pencil  of  light-rays.  This  is  done  by  throw- 
ing light  into  the  eye  by  means  of  a  mirror,  perforated  by  an 
openmg,  through  which  the  observer  looks.  Armed  with  such 
a  mirror,  with  suitable  correcting  glasses  behind  the  central 
opening,  the  observer's  eye  is  enabled  to  view  all  the  details 
of  the  background  of  the  examined  eye  and  even  to  measure 
the  refraction. 


Fig.  23. — (After  Jaeger).  Normal  appearance  of  the  fundus  of  an  eye.  Arteries 
light,  veins  black.  The  blood-vessels  of  the  choroid  shining  through  the 
retina. 

In  examining  eyes  with  the  ophthalmoscope,  we  make  use 
of  two  diflerent  methods,  called  the  direct,  and  the  indirect 
method. 


METHODS  OF  EXAMINATION.  41 

In  the  direct  method  the  observer's  eye,  armed  with  the  mir- 
ror, is  brought  as  near  to  the  examined  eye  as  is  possible, 
without  excluding  the  Hght.  The  image  seen  by  this  method 
is  the  virtual  erect  image  of  the  background  of  the  examined 
eye. 

In  the  indirect  method,  the  eye  armed  with  the  mirror,  is 
moved  from  the  examined  eye  to  a  distance  of  i^j^  or  2  feet, 
and  a  lens  of  from  2  to  3  inches  focus  is  held  before  and 
within  about  2  inches  of  the  latter.  The  observer's  eye  now 
catches  the  real  inverted  aerial  image  of  the  background  of  the 
examined  eye  at  or  near  the  focus  of  the  objective  lens. 


Fig  24. — Explains,  how  rays  of  light  from  a  candle  reflected  by  a  mirror  (M)  with  a 
central  perforation  are  thrown  into  the  eye  to  be  examined.  The  rays  of 
light  returning  from  the  eye  under  examination  are  brought  to  a  focus  (f ) 
by  a  bi-convex  lens,  of  about  three  inches  focus,  where  they  form  an  in- 
verted image  of  the  fundus  of  the  examined  eye  which  is  seen  by  the  ob- 
server (A).     This  is  called  the  indirect  method  (inverted  image). 

In  the  indirect  image  the  details  seen  are  smaller,  but  the 
field  is  larger,  in  the  direct  image  the  field  is  small,  but  the  de- 
tails are  much  larger. 

In  both  methods  we  may  use  either  artificial  light  or  diffuse 
daylight.  The  former  is  more  convenient,  and  is  generally  em- 
ployed. 

By  means  of  the  ophthalmoscope  we  are  enabled  to  scan 
very  closely  the  largest  part  of  the  back-ground  of  the  eye 
and    detect  anything    abnormal.     The    ophthalmoscope    may 


42  OPHTHALMOLOG  Y, 

further  be  used  to  examine  the  transparency  of  the  anterior 
parts  of  the  eye  and  for  the  determination  of  errors  of  refrac- 
tion, as  stated. 

The  interior  of  the  eye  may  also  be  inspected  directly  when 
eliminating  the  refractive  power  of  the  cornea,  by  placing 
it  under  water,  by  pressing  a  plain  glass  plate  against  the 
cornea  and  thus  flattening  it  (Bellarminoff),  or  by  means  of  a 
plano-concave  meniscus  placed  in  front  of  the  cornea,  with  the 
concave  side  touching  it  (Koller)  after  having  been  moistened. 

§23.  We  should  further  examine  into  the  motility  of  the 
eyes,  especially  noticing  if  the  movements  of  one  or  both  eyes 
are  restricted  or  excessive  in  any  direction.  This  mode  of  ex- 
amination is  mostly  called  for  in  cases  of  strabismus  and  in 
paralysis  of  one  or  more  of  the  external  muscles. 

Direct  the  patient  to  fix  his  gaze  upon  your  forefinger,  and 
while  moving  it  toward  and  from  his  nose  in  the  middle  line, 
observe  whether  his  binocular  fixation  is  preserved  within  the 
whole  range  of  his  accomodation.  Next  cover  one  eye  and 
let  him  look  straight  at  your  finger  with  the  other,  then  quick- 
ly removing  the  cover  from  the  first  eye,  note  whether  it 
makes  any  movement  to  come  back  to  the  point  of  fixation. 
Then  direct  him  to  follow  your  finger  in  different  directins  with 
both  eyes  and  pay  particular  attention  to  the  excursion  of 
each  eye. 

If  one  or  more  muscles  of  one  eye  (or  both)  refuse  to  act  or 
act  to  an  undue  degree  double  vision  [diplopia)  must  result,  as 
binocular  vision  is  no  longer  possible.  The  patient  will  see  a 
true  image  with  the  healthy  eye  and  a  false  one  with  the  dis- 
eased eye. 

The  examination  for  double  images  is  best  made  with  a  can- 
dle flame.  This  is  moved  before  the  patient's  eye  at  a  distance 
of  six  or  eight  feet  in  all  directions,  and  the  patient  is  directed 
to  say  when  he  sees  double.  In  order  to  enable  him  the  bet- 
ter to  distinguish  the  second  image,  one  eye,  usually  the 
healthy  one,  is  armed  with  a  colored  glass. 

Particular  attention  has  sometimes  to  be  paid  to  the  action 
of  the  internal  recti  muscles  during  convergence,  as  in  some 
people  these  muscles  refuse  continued  work.    Moving  the  fore- 


METHODS  OF  EXAMINATION.  43 

finger  towards  the  patient's  nose,  while  his  gaze  is  fixed  on  it, 
will  often  enable  us  to  detect  such  a  weakness,  one  eye  pres- 
ently diverging.  To  make  sure  of  such  an  observation,  it  is 
then  best  to  let  the  patient  look  at  a  small  object  [a  line  with 
a  dark  dot  in  the  center  {v.  Graefe)']  at  reading  distance,  while 
a  prism  with  base  up  or  downwards  is  held  before  the  suspected 
eye.  If  the  false  image  thus  produced  does  not  stand  directly 
above  or  below  the  real  one,  but  stands  also  to  one  side,  an 
insufficient  action  of  one  or  both  recti  interni  is  shown.  The 
prism,  by  means  of  which,  with  its  base  inward,  we  can  bring 
the  two  images  into  the  same  vertical  line,  gives  us  the  degree 
of  insufficiency.  However,  other  muscles  besides  the  interni 
may  be  insufficient. 

For  the  different  forms  of  insufficiency  of  the  different  ex- 
ternal muscles  of  the  eye  the  terms  of  esophoria  (tendency  to 
overconverge),  exophoria  (tendency  to  overdiverge),  and  hy- 
perphoria (tendency  to  move  too  far  upward)  have  been 
brought  into  use  by  Stevens,  To  these  are  added  the  terms 
of  hyperexphoria  and  hyperesophoria  when  one  or  the  other  of 
the  oblique  muscules  is  also  affected.  These  more  minute  in- 
sufficiencies (in  general  called  heterophoria)  which  by  some 
are  thought  to  be  of  grave  importance  may  be  best  inquired 
into  by  means  of  a  Maddox  glass-rod,  Stevens'  phorometer  or 
Savage's  double  prism,  or  some  similar  contrivance  by  which 
the  abnormal  position  and  direction  of  the  image  of  one  eye  is 
made  more  perceptible,  by  comparing  it  with  the  position  of 
the  image  of  the  fellow  eye. 


CHAPTER    III.— DISEASES    OF    THE    EYELIDS. 

§24.  The  skin  of  the  eyelids  may  be  attacked  by  all  forms 
of  skin  disease.  Among  these,  however,  several  are  more 
commonly  found  on  the  eyelids  than  others. 

Erysipelas  attacks  the  eyelids  usually  during  an  attack  of 
erysipelas  of  the  face.  It  must  then  be  treated  conjointly  with 
the  latter.  Local  applications  of  ichthyol  over  the  infiltrated 
parts  and  somewhat  over  the  neighboring  healthy  skin  with  a 
brush  are  highly  to  be  recommended. 

Herpes  Zoster  Ophthalmicus  is  that  form  of  herpes  in  which 
the  vesicles  are  found  in  the  skin  in  the  neighborhood  of  the 
eye  (and  sometimes  on  the  eyeball  itself),  where  the  terminal 
fibres  of  the  trigeminus  nerve  are  situated.  Their  appearance 
is  usually  preceded  or  accompanied  by  violent  pain.  The 
progress  of  the  disease  is  the  same  as  in  other  regions.  The 
contents  of  the  vesicles,  at  first  watery,  become  soon  purulent, 
and  finally  a  crust  is  formed  under  which  the  small  ulcer  heals, 
leaving  a  lasting  scar.  A  drying  powder  may  be  applied  with 
benefit.  No  other  treatment  is  apparently  necessary  or  of  any 
value. 

Chronic  Eczema,  when  found  on  the  lids,  is  best  treated  by 
an  ointment  containing  oxide  of  zinc. 

Varioloid  or  true  variola  pustules,  are  found  on  the  lids  dur- 
ing a  general  attack  of  these  diseases.  Peculiar  pustules  are 
produced  by  an  infection  with  animal-lymph,  and  have  been 
termed  vaccinola. 

CEdema  of  the  lids  may  be  produced  by  a  variety  of  condi- 
tions which  interfere  with  the  current  of  the  venous  blood, 
such  as  conjunctival  diseases,  inflammation  of  Tenon's  cap- 
sule, orbital  phlegmon,  inflammatory  processes  in  the  interior 
of  the  eyeball,  orbital  tumors,  or  inflammatory  processes  in 
and  around  the  lachrymal  sac.  In  these  cases  the  oedema  of 
the  lids  is  purely  symptomatic. 

—44- 


DISEASES  OF  THE  EYELIDS.  45 

In  rare  cases  an  oedema  of  one  or  both  lids  of  one  eye,  or 
of  both  eyes  is  seen  to  take  place  without  any  known  cause. 
Such  an  oedema  generally  disappears  as  it  has  come,  without 
any  interference. 

In  som.e  patients  the  exhibition  of  large  doses  of  some 
iodide  salt  causes  an  acute  oedema  of  the  lids,  which  disap- 
pears as  soon  as  this  remedy  is  withdrawn. 

§25.  The  most  frequent  affection  of  the  lids  is  confined  to  the 
lid-margins  and  is  called  blepharitis  ciliaris  or  marginalis  or 
blepharadenitis. 

The  prominent  symptoms  of  this  affection  are  the  formation 
of  scales  or  larger  crusts  along  the  lid-margin,  at  the  roots  of 
the  eye-lashes,  also  redness  and  swelling,  which  latter  are  usu- 
ally confined  to  the  lid-margin. 

When  the  disease  progresses,  the  original  small  scales  are 
replaced  by  larger  crusts,  in  which  the  eye-lashes  are  often 
totally  embedded.  The  swelling  increases  sometimes  to  such 
an  extent  that  the  lid-margin  is  turned  outward  from  the  eye, 
thus  giving  rise  to  an  ectropium,  especially  of  the  lower  eye- 
lids. Such  an  inflammation  cannot  exist  for  a  long  period 
without  affecting  the  eyelashes  also.  They  fall  out,  their 
bulbs  become  atrophied,  and  when  the  inflammation  has  finally 
passed  away,  the  eyelids  remain  more  or  less  destitute  of  eye- 
lashes (madarosis).  Blepharitis  ciliaris  is  mostly,  in  its  severer 
or  chronic  forms  always,  combined  with  some  degree  of  ca- 
tarrhal conjunctivitis. 

From  the  beginning  the  disease  causes  a  disagreeable  feel- 
ing of  heat,  irritation  and  weakness,  when  the  eyes  are  used 
for  small  objects.  In  the  morning  the  eye-lashes  are  glued  to- 
gether by  the  dried  secretion. 

The  affection  is  chiefly  one  of  childhood,  although  it  is  ob- 
served in  adults  also.  Children  of  a  strumous  habit  and  of  a 
fair  complexion  are  perhaps  oftenest  subject  to  it. 

The  origin  of  the  disease  is  probably  an  infection  by  micro- 
organisms, due  to  rubbing  the  lid-margins  with  dirty  fingers 
or  a  handkerchief  soiled  with  nasal  secretions. 

We  may  distinquish  between  a  blepharitis  squamosa  and  a 
blepharitis  ulcerosa.     While  in  the  former  the  skin  beneath  the 


46  OPHTHALMOLOGY, 

scales  is  red  and  swollen,  but  otherwise  more  or  less  intact,  in 
the  latter  form  we  find  small  ulcers  and  abscesses  under  these 
scales.  These  ulcers  and  abscesses  are  due  to  pyogenous  in- 
fection of  the  hair-follicles  and  sebacious  glands  of  the  lid- 
margin. 

Blepharitis  ciliaris  does  not,  as  a  rule,  yield  easily  to  treat- 
ment, and  in  its  wor^t  forms  a  restitutio  ad  integrum  is  almost 
impossible.  Where  a  strumous  habit  exists,  internal  treat- 
ment should  always  be  combined  with  the  local  one. 

The  treatment  which  yields  the  best  results  in  mild  cases  of 
blepharitis,  is  the  following :  Bathe  the  eyelids  with  luke-warm 
water  until  the  scabs  are  well  soaked.  They  can  then  readily  be 
removed  by  rubbing  along  the  lid-margin  back  and  forth  with 
a  dry,  rough  towel.  If  luke-warm  water  does  not  seem  to 
soak  them  sufficiently,  the  application  of  white  vaseline 
will  do  so.  When  all  the  scabs  have  been  carefully  removed, 
apply  a  small  quantity  of  an  ointment,  containing  from  2  to  4 
grains  of  yellow  oxide  of  mercury  to  3  or  4  drachms  of 
white  vaseline  or  lanoline,  or  10  grains  of  aristol  to  i  drachm 
of  white  vaseline  or  lanoline.  This  is  to  be  rubbed  into  the 
roots  of  the  eyelashes  while  the  eyelids  are  kept  closed.  Af 
ter  having  allowed  it  to  remain  there  for  a  few  minutes, 
the  surplus  ought  to  be  gently  wiped  off.  This  application 
must  not  be  made  just  before  the  patient  retires,  but  several 
hours  earlier.  If  any  of  the  ointment  gets  accidentally  into 
the  conjunctival  sack  it  may  cause  considerable  smarting,  but 
it  will  do  no  harm.  If  the  catarrhal  conjunctivitis  is  at  all  pro- 
nounced it  should  also  be  treated.     (See  Chapter  VII). 

In  severer,  especially  the  ulcerous,  cases  where  large  crusts 
glue  the  eye-lashes  together  and  cover  an  ulcerated  lid-mar- 
gin, it  is  best  to  soften  the  crusts  with  white  vaseline. 
We  are  often  obliged  to  remove  such  crusts  with  the  forceps. 
This  should  be  done  very  carefully  and  gently.  When  we 
have  succeeded  in  thoroughly  removing  the  ^  crusts,  the  oint- 
ment of  oxide  of  mercury  should  be  applied.  It  will,  how- 
ever, but  rarely  suffice  in  these  forms  of  blepharitis,  and  we 
are  often  compelled  to  resort  to  a  caustic  treatment.  The  ap- 
plication of  a  2  or  3  per  cent,  solution  of  nitrate  of  silver  with 
a  camel's  hair  brush,  while  carefully   shielding  the   eyeball,  is 


DISEASES  OF  THE  EYELIDS.  47 

highly  to  be  recommended.  In  some  cases  the  solid  nitrate 
of  silver  stick  must  be  used.  In  other  cases  tar  or  oleum  rhus- 
ci,  either  pure  or  mixed  with  vaseline,  is  very  useful.  Epila- 
tion of  the  diseased  cilia,  and  burning  the  ulcerations  by 
means  of  actual  or  galvano-cautery  may  often  be  used  with 
great  success. 

Such  applications  should  not  be  discontinued  at  once,  when 
the  ulceration  is  healed,  but  be  continued  for  a  longer  period, 
until  all  swelling  and  irritability  of  the  tissues  of  the  lid-margin 
have  disappeared. 

Such  treatment,  to  ensure  perfect  success  is,  at  least  in  the 
severe  cases,  best  applied  by  the  surgeon  himself.  He  may, 
however,  be  in  a  great  measure  assisted  by  the  patient.  The 
patient  ought  to  bathe  his  closed  eyelids  frequently  with  cold 
water,  or  apply  cold  compresses  to  them.  He  must  refrain  from 
using  his  eyes  for  all  occupations,  which  are  likely  to  irritate 
them,  especially  by  artificial  light.  Children  should  be  kept 
from  school,  and  be  given  a  separate  clean  handkerchief  to 
wipe  their  eyes  with.  Adults  should  not  smoke  in  a  close 
room  or  stay  in  rooms  where  others  are  smoking.  Fresh  air 
is  not  injurious.  If  blepharitis  ciliaris  is  observed  in  a  patient 
whose  eyes  are  ametropic  (show  an  error  of  refraction),  and 
especially,  it  they  are  hypermetropic  or  astigmatic,  the  cor- 
rection of  the  ametropia  by  glasses  will  have  a  beneficial  in- 
fluence on  the  result  of  the  treatment. 

§26.  Phthiriasis,  an  affection  of  the  lid-margin  which  may 
simulate  blepharitis  #  ciliaris,  is  caused  by  the  presence  of 
crab-lice  {pediculi  pubis)  upon  the  eyelashes.  The  patient, 
who  is  usually  unaware  of  their  presence,  feels  a  great  irrita- 
tion on  the  lid-margin,  and  by  repeated  scratching,  often 
produces  such  a  condition  of  the  lid-margins  as  may  easily  be 
mistaken  for  blepharitis  ciliaris.  On  closer  inspection  the 
eggs  of  the  parasite  are  seen  adhering  to  the  eyelashes,  and 
the  parasites,  themselves,  may  be  recognized  burrowing  into 
the  openings  of  the  hair  follicles. 

The  treatment  consists  simply  in  the  application  of  some 
mercurial  ointment.  Among  them  the  common  blue  oint- 
ment is    as  good  as  any.     About  a  quarter  of  an   hour  after 


48  OPHTHALMOLOGY. 

this  has  been  rubbed  into  the  affected  lid-margins,  the  para- 
sites will  have  come  out  of  the  glandular  orifices,  into  which 
they  have  burrowed  their  heads,  and  can  then  be  easily  re- 
moved with  the  forceps.  The  application  may  be  repeated  if 
necessary.  The  eggs  ought  to  be  seized  singly  between  the 
teeth  of  the  forceps  and  gently  pulled  along  the  eyelashes,  to 
which  they  are  adherent.  This  is  the  easiest  method  of  re- 
moving them,^and  much  better  than  cutting  off  the  eyelashes. 
As  soon  as  the  irritating  cause  is  removed,  the  inflammatory 
symptoms  disappear. 

§27.  The  acute  inflammation  of  the  orifice  of  a  Meibomian 
or  tarsal  gland,  and  later  of  the  gland  itself,  is  called  hordeo- 
lum, commonly  stye.  It  begins  with  a  slight  circumscribed 
redness  and  swelling  at  the  lid -margin  {hordeolum  externum), 
or  farther  back  on  the  inner  side  of  the  eyelid  (hordeolum  in- 
ternum) which  is  often  exceedingly  painful.  The  swelling 
gradually  increases  and  may  lead  to  oedematous  swelling  of 
the  whole  affected  lid,  so  that  it  may  appear  like  a  very  seri- 
ous inflammation.  Soon,  however,  the  swelling  comes  to  a  head 
at  the  orifice  of  the  gland,  or  on  the  conjunctival  surface  of  the 
lid,  and,  if  it  breaks  and  the  pus  is  discharged,  the  inflamma- 
tory symptoms  will  subside.  The  result  may  be  hastened  by 
hot  fomentations. 

The  best  way  to  treat  a  stye  is  to  split  the  swelling  in  its 
beginning  with  a  narrow  knife  or  lancet  in  a  direction  at  right 
angles  to  the  lid-margin.  The  depletion  and  consequent  de- 
crease of  tension  in  the  affected  parts,  and  sometimes  the  re- 
moval of  an  actual  obstruction,  will  cut  short  the  inflammatory 
process  and  the  patient's  suffering. 

A  weakened  constitution  or  strumous  habit  seems  often  to 
be  a  predisposing  cause  of  this  affection,  and  such  patients 
sometimes  suffer  habitually  from  styes.  Tonic  treatment  is 
therefore  sometimes  indicated. 

The  main  cause,  however,  is  probably  a  direct  infection 
of  the  Meibomian  glands  by  micro-organisms  due  to  rubbing 
with  a  dirty  handkerchief  or  finger.  This  fact  explains,  also, 
in  a  simple  manner,  how  it  happens,  that  when  once  one  stye 
has  appeared,  more  are  likely  to  supervene. 


DISEASES  OF  THE  E  YELIDS.  49 

When  the  pus  and  detritus  filling  the  infected  Meibomian 
gland  are  not  removed  by  bursting  on  the  conjunctival  surface 
or  by  the  surgeon's  knife,  a  tumor  results  which  is  called  chala- 
zion or  tarsal  tumor.  The  acute  inflammatory  symptoms  may 
have  subsided  before  it  was  or  when  it  is  noticed,  and  may 
sometimes  be  rekindled  during  its  formation.  As  a  rule,  how- 
ever, the  formation  of  such  a  cystic  tumor  is  comparatively 
painless,  and  so  long  as  it  remains  small  it  may  cause  no  incon- 
venience. 

Such  tarsal  tumors  sometimes  disappear  without  surgical 
interference  by  absorption,  and  then  leave  no  trace  behind. 
In  most  cases,  however,  they  remain  stationary,  or  even  grow 
steadily.  When  they  have  attained  a  considerable  size,  and 
especially  when  they  lie  in  the  upper  eyelid  and  near  the  lid- 
margin,  they  are  not  only  disfiguring,  but  cause  disagreeable 
symptoms,  and  become  very  annoying.  They  may  even  ob- 
struct a  part  of  the  visual  field. 

The  contents  of  the  larger  tarsal  tumors  are  usually  no 
longer  fluid  or  only  partially  so.  They  become  organized,  and 
form  granulation  tissue,  which  is  enclosed  in  a  dense  connective 
tissue  sack.  In  some  cases  these  tumors  are  firm  and  of  a 
fibrous  or  even  enchondromatous  character. 

The  best  way  to  deal  with  the  tarsal  tumors  is  to  enucleate 
them.  This  is  done  by  means  of  a  horizontal  cut  through  the 
cutaneous  surface  of  the  eyelid.  This  operation  may  be  made 
bloodless  by  the  use  of  Knapfs  lid-clamp.  Such  a  cut  will 
leave  no  visible  scar.  Only  a  clean  and  perfect  removal  of 
the  whole  cyst-wall  will  afford  security  against  a  relapse. 

Some  surgeons  prefer  to  remove  tarsal  tumors  from  the  con- 
junctival surface  of  the  eyelid,  and  by  means  of  a  sharp 
spoon. 

The  smaller  tumors,  when  of  a  soft  consistency  and  before 
a  tough  cyst-wall  has  been  formed,  may  be  opened  from  the 
conjunctival  surface  of  the  eyelid  by  an  incision  at  right 
angles  to  the  lid-margin  and  parallel  with  the  ducts  of  the 
Meibomian  glands  and  then  effectually  squeezed  out  by  means 
of  Ayres'  chalazion  forceps  or  between  the  fingers. 

§28.     Phlegmonous    abscesses  in  the   subcutaneous  tissue  of 


50  OPHTHALMOLOGY. 

the  lid  are  comparatively  rare.  They  cause  redness,  heat  and 
swelling,  and  fluctuation  soon  can  be  felt.  As  soon  as  the 
diagnosis  is  secured,  a  knife  should  be  plunged  into  the  swol- 
len part  in  a  horizontal  direction,  and  the  pus  thus  be  eva- 
cuated. 

Syphilitic  ulcers^  primary  as  well  as  from  constitutional  sy- 
philis, have  been  observed  on  the  eyelids.  They  call  for  no 
other  treatment  than  the  manifestations  of  syphilis  do  in 
other  parts  of  the  skin. 

Warts  and  homy  excrescences  on  the  lids  are  of  little  impor- 
tance, and  may  be  simply  cut  off  with  scissors. 

Xanthelasma  is  a  yellowish  or  brown  tumor  of  the  skin.  It 
usually  lies  near  the  inner  margin  of  the  orbit  in  the  integu- 
ment of  the  upper  eyelid.  It  appears  often  in  symmetrical 
spots  on  both  upper  eyelids  and  forms  only  a  slight  elevation. 
This  growth  is  perfectly  harmless,  but  if  the  patients,  mostly 
females,  desire  its  removal,  a  clip  of  the  scissors  will  easily 
accomplish  it. 

Sarcomatous  growths  are  but  very  rarely  observed  in  the 
eyelids  as  a  primary  affection,  but  epitheliomata  quite  frequent- 
ly originate  in  this  region.  They  appear  generally  on  the 
lower  eyelid,  near  one  of  the  angles,  more  frequently  on  the 
inner  angle,  of  the  palpebral  fissure. 

These  malignant  tumors  often  take  their  origin  from  a  pre- 
existing wart,  or,  if  not,  they  resemble  such  a  harmless 
growth  very  much  in  their  early  stages.  Gradually  the  wart 
becomes  somewhat  sore  on  the  surface,  and  a  little  scab  is 
formed,  soon  grows,  and  when  removed,  reveals  an  ulcerated 
surface  underneath.  The  tumor  slowly  spreads  and  eats 
away  more  and  more  of  the  lid-margin,  and  it  gradually  pro- 
duces an  irregularly  shaped,  nodular,  hard  swelling  of  the  ad- 
jacent tissue.  The  eversion  of  the  lid-margin  caused  by  its 
presence,  or  perhaps  the  destruction  of  the  lachrymal  canal- 
iculus, allows  the  tears  to  drop  continually.  This  and  the  irri- 
tation from  the  partially  unprotected  state  of  the  eyeball,  be- 
come more  and  more  annoying.  Sometimes  a  very  distressing 
shooting  pain  accompanies  the  growth  of  the  tumor. 

In  case  it  is  not  interfered  with,  the  epithelioma  may  ex- 
tend   to    the   ocular  conjunctiva,  and  thus  an    epitheliomatous 


DISEASES  OF  THE  EYELIDS. 


51 


symblepharon  may  be  formed.  In  this  way  the  newforma- 
tion  may  even  enter  the  interior  of  the  eyeball  and  spread 
there. 

The  growth  of  the  tumors  is  slow,  and  a  patient  may  suffer 
from  them  a  very  long  time  before  they  attain  a  fatal  develop- 
ment, if  this  ever  happens. 

The  only  treatment  which  promises  a  radical  cure  in  sarco- 
matous or  epitheliomatous  tumors  of  the  eyelids  is  their  early 
destruction  by  galvano-cautery,  or  their  removal  by  excision. 
This  latter  operation  must  of  course  be  done,  according  to 
the  general  surgical  rules  for  the  removal  of  malignant 
tumors. 

According  to  the  size  and  situation  of  the  newformation, 
its  removal  will  cause  a  more  or  less  important  loss  of  sub- 
stance of  the  affected  eyelid,  which  my  have  to  be  made  good 
by  means  of  a  plastic  operation.  In  most  cases  a  part  of  the 
lid-margin  and  a  piece  of  healthy  eyelid  will  be  left  after  the 
removal  of  the  tumor,  and  these  should  be  carefully  made  use 
of. 

In  such  cases  I  consider  the  method  for  repairing  the  loss  of 
substance    by   sliding  flaps  {Knapp)  (See    Figs.    25    and    26), 


Fig.  25. — Malignant  tumor  involving  the  inner  two-thirds  of  the  lower  lid.  Show- 
ing the  incisions  (Knapp's  method)  made  in  order  to  fill  the  gap  resulting 
from  its  removal,  by  sliding  flaps. 


as  generally  the  most  satisfactory  and  least  disfiguring 
one.  It  consists  in  the  following  procedure:  If  the  new- 
formation  involves,  for  instance,  the  inner  two  thirds  of 
the  lower  lid-margin  and  eyelid,  we  shall  have,  after  its 
removal,  an  extensive  gap  between  the  inner  canthus  and 
the    remaining    healthy     part    of  the    eyelid.       To    fill  this 


52  OPHTHALMOL  OGY, 

gap,  we  make  an  incision  through  the  outer  canthus  in  a 
horizontal  direction  towards  the  temple,  allowing  its  end  to  run 
slightly  upwards,  and  a  similar  incision  from  the  outer  lower 
angle  of  the  loss  of  substance  outwards  towards  the  ear,  al- 
lowing its  end  to  run  slightly  downwards.  The  nearly  rectan- 
gular flap  thus  formed  contains  at  its  nasal  end  the  remaining 
healthy  portion  of  the  eyelid.  When  this  flap  is  carefully  dis- 
sected from  the  underlying  tissues,  it  is  best  to  try  whether, 
without  dangerous  stretching,  it  will  cover  the  gap.  This  is 
usually  not  the  case,  and  another  small  flap  must  be  dissected 
from  the  inner  canthus,  and  from  the  side  of  the  nose.  These 
flaps  are  drawn  over  the  gap  and  are  carfuUy  stitched  together 
and  to  the  skin  below.  Although  this  newly-formed  eyelid 
presents  now  a  raw  wound-surface  towards  the  ocular  conjunc- 
tiva, it  gradually  becomes  lined  during  the  healing  process  by 
an  epithelial  coat,  derived  from  the  part  of  the  conjunctiva, 
which  has  been  preserved.  The  disfigurement  caused  by  the 
scars  is  trifling,  when  the  wound-lips  have  united  well. 


^^<^ 


^H-H-H-l-nL  \  11  hK. 


Fig.  26. — Showing  the  sliding  flaps  united  by  sutures. 

In  some  cases  of  tumor  of  the  lower  lid  {Denonvilliers)  it 
may  be  well  to  stitch  the  margin  of  the  upper  lid  denuded  of 
of  the  cilia-bearing  border  to  the  wound  lips  of  the  gap  result- 
ing from  the  excision  of  the  tumor.  When  all  the  parts  are  well 
healed  together,  a  new  palpebral  fissure  is  made  by  carefully 
cutting  transversely  through  the  upper  lid  in  front  of  the 
cornea.  In  this  way  two  lids  are  made  of  one  and  the  eye 
can  still  be  opened  and  closed  at  will. 

In  some  cases  it  may  be  necessary  to  supply  the  loss  of 
substance  by  means  of  twisted  flaps. 


DISEASES  OF  THE  EYELIDS.  53 

Every  case,  however,  must  be  operated  upon  according  to 
its  own  conditions,  and  the  general  rules  applied  to  plastic 
surgery  must  govern  us. 

The  same,  or  similar  (flap  without  a  pedicle)  methods  may 
be  applied,  whenever  a  part  of  the  eyehd  is  destroyed  by 
some  other  cause.  Care  must,  however,  always  be  taken  to 
preserve  whatever  is  left  of  a  healthy  Hd-margin  and  eyelid. 

Tele  angle  ctatic  and  angiomatous  growths  are  not  infrequent 
on  the  eyelid,  especially  on  the  upper  ones.  They  form  reddish 
or  dark  bluish,  soft  tumors  under  the  skin  of  the  eyelid  some- 
times reaching  deep  into  the  orbital  tissue,  and  are  usually 
congenital.  They  are  compressible  to  a  certain  degree  and 
increase  in  size  when  the  patient  stoops,  cries  or  coughs. 
These  tumors  ought  to  be  removed,  completely  and  as  early 
as  possible,  and  the  knife  or  scissors  is  the  preferable  means 
for  their  removal.  Injections  of  sesquichloride  of  iron,  the 
use  of  the  actual  and  galvano-cautery,  etc.,  are  less  reliable 
or  are  followed  by  a  more  disfiguring  scar. 

§30.  Different  forms  of  disease  of  the  eyelids  and  of  the 
palpebral  conjunctiva  cause  the  eyelashes  to  grow  in  an  ab- 
normal direction.  This  condition  is  called  distichiasis  or 
trichiasis.  It  becomes  very  annoying  as  soon  as  the  eyelashes 
touch  the  eyeball,  as  the  cornea  is  continually  scratched  by 
them. 

This  constant  irritation  of  the  corneal  tissue  causes  it  to  be- 
come inflamed  and  often  to  partially  or  totally  lose  its  transpar- 
ency by  the  formation  of  scars.  The  trouble  is  most  easily 
remedied  in  its  incipiency. 

It  is  very  common  for  such  patients  to  pull  out  the  offend- 
ing cilia,  as  well  as  they  can,  with  all  sorts  of  instruments  and 
thus  to  relieve  themselves  for  a  time.  The  surgeon  should, 
however,  not  be  satisfied  with  such  a  palliative  remedy,  the 
effect  of  which  vanishes  after  a  few  days.  A  lasting  effect  can 
only  be  produced  by  a  surgical  operation,  which  forces  the 
eyelashes  to  stand  in  a  direction  from  the  eyeball. 

If  there  is  only  one  or  if  there  are  but  a  few  eyelashes  which 
rub  against  the  cornea,  they  may  be  removed  with  their  bulbs 
by  the    simple    excision  of  a  small   wedge  of  tissue    from  the 


54 


OPHTHALMOL  OGY, 


lid-margin,  including  their  bulbs.  Electrolysis  which  is  used 
by  some  surgeons  for  the  destruction  and  removal  of  lashes, 
is  a  very  painful  procedure,  and  appears  to  prove  very  often  a 
source  of  future  disappointment. 

Of  the  different  operations  devised  for  the  cure  of  trichiasis 
the  method  of  Hotz  (See  Fig.  27)  is  a  very  effective  one.     Its 


Fig.  27. — Hotz's  method  of  operating  for  trichiasis.  Showing  gap  resulting  from 
excision  of  skin  and  muscle  down  to  the  tarso-orbital  fascia  at  upper  edge 
of  tarsus  and  the  manner  in  whicli  the  sutures  are  passed  to  unite  the  gap. 

main  point  is  that  the  skin  of  the  lid  is  forced  to  adhere  to  a 
fixed  point,  for  which  he  has  chosen  the  tarso-orbital  fascia,  in 
the  upper  eyelid  just  above  the  tarsal  tissue,  in  the  lower  one 
just  below  it.  An  incision  is  carried  through  the  skin  and 
muscle  down  to  the  fascia  along  the  upper  edge  of  the  tarsus. 
A  strip  of  the  muscular  tissue  is  then  removed  and  the  parts 
are  united  by  four  or  five  sutures,  going  first  through  skin  and 
fascia,  and  then  through  fascia  and  skin  on  the  opposite  side 
of  the  wound.  The  simple  method  yields  good  and  apparent- 
ly lasting  results  even  in  bad  cases  of  trichiasis. 

More  recently  the  implantation  of  a  flap  of  skin  between  the 
lips  of  the  lid-margin,  which  is  split  in  two  portions  by  a  verti- 
cal incision  along  the  lid,  has  been  successfully  practiced. 


DISEASES  OF  THE  EYELIDS.  55 

Trichiasis  is  very  frequently  accompanied  by  a  change  in 
the  curvature  of  the  tarsus,  which  causes  the  edge  of  the 
tarsus  also  to  rub  against  the  eyeball.  This  condition  is 
called  eiitropium.  It  is  mostly  the  result  of  chronic  trachoma 
of  the  conjunctiva,  commonly  called  granulated  eyelids. 

A  large  number  of  operations  have  been  devised  and  are 
used  to  remedy  this  troublesome  affection,  which  materially 
endangers  the  usefulness  of  the  eyes.  A  very  successful 
method  is  to  cut  a  wedge-shaped  piece  out  of  the  tarsal  tis- 
sue, near  and  parallel  to  the  lid-margin,  after  having  removed 
the  corresponding  strips  of  skin  and  muscle.  When  the 
wound-lips  are  united  by  sutures,  the  lid-margin  is  turned 
outwards  and  thus  relief  is  obtained  Relapses  are  com- 
paratively rare  after  this  operation,  which,  however,  shortens 
the  eyelid  \S7iellen'Streatfeild\ 

Hotz's  operation,  just  described,  does  also  well  in  milder  cases 
of  entropium.     In  severer  ones  I  perform  Green's  (See  Fig.  28) 


Fig.  28. — Green's  method  of  operating  for  trichiasis  and  entropium.  Showing  in- 
cision through  tarsus  on  the  inner  side  and  excision  of  skin  on  the  outer 
side,  and  the  manner  in  which  the  sutures  are  passed  through  the  tissues 
before  beinij  tied. 

operation  with  preference.  The  lid-margin  in  this  method  is 
freed  by  an  incision  through  the  conjunctiva  and  tarsal  tissue, 
running  parallel  with  and  about  two  millimeters  removed  from 


56  OPHTHALMOL  OGY. 

it.  When  by  this  incision  all  tough  bands  of  tissue  have  been 
severed,  the  tension  is  at  once  relieved.  To  render  this  mo- 
mentary effect  permanent  it  is  usually  necessary  to  remove  a 
narrow  strip  of  skin  opposite  the  tarsal  incision  and  to  insert 
a  few  sutures,  which  are  entered  near  the  posterior  edge  of  the 
lid-margin,  brought  out  at  the  lower  wound-lip,  then  entered 
again  at  the  upper  wound-lip  and  running  along  for  some  dis- 
tance on  the  tarsal  tissue  come  out  through  the  muscle  and 
skin.  These  sutures  may  be  removed  the  next  day,  or  they 
may  be  allowed  to  remain  a  few  days.  The  requirements  in 
each  case  may  alter  the  procedure  slightly. 

In  some  cases  it  may  be  necessary  to  combine  canthotomy 
or  canthoplasty  (see  later)  with  the  operations  for  trichiasis  and 
entropium. 

§31.  When  the  lid-margin  is  turned  outwards,  away  from 
the  eye-ball,  the  condition  is  called  ectropium.  This  concerns 
mostly  the  lower  eyelids,  while  entropium  is  observed  on  the 
upper  eyelids  especially.  It  very  frequently  affects  chiefly  the 
nasal  part  of  the  eyelid,  but  it  may,  of  course,  involve  the 
whole  of  it.  It  is  usually  caused  by  the  shrinkage  of  cicatri- 
ces of  injuries  or  burns,  or  following  inflammatory  condi- 
tions of  the  skin,  as  in  blepharitis  marginalis. 

The  epiphora  and  stillicidium  (dropping  of  the  tears),  and 
the  irritation  and  often  very  great  swelling  of  the  conjunctiva, 
caused  by  its  continued  exposure  to  the  air,  call  for  surgical 
interference,  and  often  the  operation  required  seems  very  ex- 
tensive in  comparison  with  the  seeming  triviality  of  the  affec- 
tion. This  is  especially  the  case  in  that  most  frequent  form  of 
ectropium,  when  it  is  due  to  the  retraction  of  cicatricial 
tissue. 

If  the  ectropium  is  small  it  may  often  be  remedied  by  the 
excision  of  a  rhomboid  piece  of  the  whole  thickness  of  the 
eyelid  with  the  long  diagonal  in  a  vertical  direction  {Adams). 
(See  Fig.  29).  If  the  wound-lips  are  now  sewed  together,  the 
formerly  everted  part  of  the  lid-margin  will  at  first  be  raised 
considerably  above  the  neighboring  parts  of  the  lid-margin. 
Later  on  the  retraction  of  the  scar  will  bring  it  down  to  the 
proper  level. 


DISEASES  OF  THE  EYELIDS,  57 

In  other  cases  the  removal  of  a  triangular  piece  of  tissue 
from  the  outer  angle  of  the  palpebral  fissure  and  stitching  the 
corner  of  the  lower  eyelid  into  the  upper  corner  of  the  wound 
will  serve  to  overcome  the  eversion. 


Fig.  29. — Adams'  operation  for  ectropium. 

When  the  ectropium  is,  however,  very  extensive,  it  will  re- 
quire the  removal  of  the  scar-tissue  and  some  form  of  a  plas- 
tic operation.  In  this  we  may  make  use  of  twisted  or  sliding 
flaps,  or  flaps  without  a  pedicle,  according  to  general  surgical 
rules,  and  as  it  seems  best  for  the  case  under  consideration. 

§32.  Drooping  of  the  upper  eyelid  with  a  total  or  partial 
inability  to  lift  it  enough,  to  expose  the  pupil  for  convenient 
sight,  is  called  ptosis.  It  may  be  either  congenital  or  due  to 
an  acquired  paralysis  of  the  levator  palpebrae  superioris  mus- 
cle. If  congenital,  it  usually  concerns  both  upper  eyelids  and 
the  levator  palpebrae  superioris  muscles  are  atrophic  or  totally 
wanting.     The  paralytic  ptosis  is  frequently  one-sided. 

Von  Graefe's  method  of  operating  for  congenital  or  paralyt- 
ic ptosis,  consists  in  the  removal  of  a  horizontal  fold  of  the 
skin  and  muscle  from  the  upper  eyelid  followed  by  stitching 
of  the  wound.  In  doing  this  the  aim  must  be  to  shorten  the 
eyelid  sufficiently  for  convenient  vision  and  yet,  to  leave  it 
long  enough  to  cover  and  protect  the  cornea  during  sleep.  In 
consequence  the  result  of  this  operation  is  usually  rather  in- 
adequate, except  in  slight  cases,  and  it   has    fallen    somewhat 


58 


OPHTHALMOL  OGV. 


into  discredit.  Macnamara  recommends  to  combine  with  the 
excision  of  the  skin  and  muscle  an  artificial  elongation  of  the 
pupil  downwards  (by  iridectomy),  and  this  seems  to  be  a  rea- 
sonable procedure  and  calculated  to  make  this  form  of  ptosis- 
operations  more  useful. 

Two  more  modern  operative  procedures,  devised  respectively 
by  Pagenstecher  dcwd  Panas,  make  use  of  the  frontalis  muscle  to 
raise  the  lid.  In  Pagenstecher' s  method  loops  of  thread  are 
passed  in  through  the  tissue  above  the  eyebrow,  and  having 
been  brought  out  on  the  surface  of  the  skin  of  the  lid  are  tied 
on  rolls  of  plaster  or  glass  beads.  These  loops  are  allowed 
to  remain  until  suppuration  has  taken  place  in  their  channels. 
In  this  manner  cicatrices  are  formed  which  are  said  to  allow 
the  action  of  the  frontal  muscle  to  successfully  lift  the  eyelid. 
Panas  tries  to    reach  the  same    result  in    what  seems  to  be    a 


Fig.  30. — Panas'  method  of  operating  ior  ptosis  of  the  upper  lid. 


more  efficient  and  surely  is  to  the  modern  surgeon,  a  more  ac- 
ceptable manner.  He  forms  a  quadrangular  flap  at  the  upper 
part  of  the  lid  which  is  freed  from  the  underlying  tissue.  Then 
a  horizontal  incision  if  made  through  the  skin  above  the  eye- 
brow.    The  bridge   between    the    upper  end  of  the   flap  and 


DISEASES  OF  THE  EYELIDS.  59 

this  incision,  formed  by  the  eyebrow  and  the  skin  below  it,  is 
now  undermined,  and  the  lid-flap  is  drawn  upward  underneath 
it  and  stitched  to  the  upper  wound-lip  of  the  incision  above 
the  eyebrow  by  means  of  a  loop  of  thread.      (See  Fig.  30). 

Advancement  of  the  tendon  of  the  levator  palpebrae  superi- 
ors muscle  has  also  been  tried  {Eversbusch). 

In  the  paralytic  form  of  ptosis  an  operation  must,  of  course, 
not  be  resorted  to,  until  internal  and  galvanic  treatment  have 
been  tried  and  proved  unseccessful.  It  is  most  frequently  due 
to  syphilis  and  then  usually  yields   to  antisyphilitic  treatment. 

There  is  another  affection  very  similar  to  ptosis,  which 
is  chiefly  observed  in  older  people  and  *which  is  not 
due  to  a  muscular  affection  but  to  a  superfluity  and  excess- 
ive looseness  of  the  skin  of  the  upper  eyelid.  It  is  called 
prolapse  of  the  skin  of  the  eyelid  or  ptosis  atonica.  A  similar 
condition  is  also  observed  on  the  lower  lid  of  old  people, 
causing  the  lashes  to  irritate  the  eye.  In  these  affections 
Hoizs  method  of  operating  for  trichiasis,  as  described  above^ 
is  most  satisfactory. 

§33.  The  orbicularis  palpebrarum  muscle  is  sometimes  sub- 
ject to  tonic  and  clonic  spasms,  called  blepharospasmus.  In 
the  incipient  stage  such  spasms  may  concern  only  a  few  mus- 
cular fibres,  and  they  are  then  felt  and  seen,  as  a  slight 
tremor  of  the  skin  of  the  eyelid  near  the  lid-margin.  This 
slight  degree  of  blepharospasmus  is  not  rare,  and  it  is  often 
observed  in  overworked  individuals,  or  after  excesses  in  venere 
or  in  baccho,  and  will  then  disappear  without  treatment.  In 
other  cases  it  develops  into  a  more  serious  form,  in  which  the 
patient  is  forced  to  wink  his  eyelids  almost  continually,  especi- 
ally when  trying  to  gaze  steadily  at  something,  when  watched 
by  another  person,  or,  when  in  the  least  excited.  These 
spasms  may  be  clonic  and  tonic  at  the  same  time.  In  such 
cases  the  blepharospasmus  is,  as  a  rule,  combined  with  similar 
clonic  spasms  of  the  facial  muscles.  The  spasms  may  be  uni- 
lateral, but  are  usually  bilateral.  This  affection  is,  of  course, 
a  most  annoying  one  and  it  is  very  difficult  to  cure.  Over- 
stretching of  the  orbicular  muscle,  subcutaneous  injections  of 
morphine,  and  local  applications  of  the  constant  current  seem 


60  -  OPHTHALMOLOG  V. 

to  yield  the  best  results.     In  very  severe  cases  neurectomy  of 
the  supra-orbital  and  infra-orbital  nerves  must  be  tried. 

Spasmodic  entropium  of  the  eyelids  and  chiefly  of  the  lower 
lid  is  the  consequence  of  a  tonic  spasm  of  the  orbicularis  pal- 
pebrarum muscle,  and  is  frequently  observed  in  affections  of 
the  cornea  and  conjunctiva,  especially  in  children.  It  gener- 
ally disappears  when  the  irritating  cause  is  removed,  but  may 
sometimes  necessitates  canthotomy  or  other  operations.  (See 
later  on). 

§34.  Paralysis  of  the  orbicularis  palpebrarum  muscle  causes 
inability  to  close  the  eye  or  to  wink  the  eyelids,  so  that  the 
cornea  remains  unprotected  even  during  sleep.  This  affection 
has  been  called  lagophthalmus  (hare  eye),  as  an  old  fable  states. 


Fig.  31. — Method  of  freshening  the  lids  for  tarsorraphy  in  lagophthalmus. 

that  the  hare  sleeps  with  open  eyes.  It  is  one  of  the  symptoms 
of  paralysis  of  the  facial  nerve  and  may  be  either  a  paresis  or  a 
total  paralysis.  The  dangers  arising  from  the  continued  expo- 
sure of  the  cornea  are  evident.  If  the  paralysis  is  of  long 
standing,  and  no  longer  curable  by  the  treatment  for  the  ner- 
vous disease,  these  dangers  to  the  eyeball  will  call  for  aid  from 
the  ophthalmic  surgeon. 

The  cornea  may  be  partly  protected  and  the  eversion  of  the 
lower  lachrymal  punctum,  which  always  occurs  in  the  later 
stages  of  this  affection,  may  be  relieved  to  a  certain  extent  by 
shortening  the  palpebral  fissure.  This  little  operation,  which 
is  called  tarsorraphy,  consists  in  removing  a  small  strip  of 
skin  including  the  hair-bulbs  from  the  lid-margin  of  both  eye- 
lids to  an  equal  distance  from  the  outer  angle  of  the  palpebral 
fissure.     (See  Fig.  31). 

The  pared  edges  are  then  sewed  together.      In  some  cases 


DISEASES  OF  THE  EYELIDS.  61 

it  may  be  necessary  to  shorten  the  palpebral  fissure  from  the 
inner  angle  also,  and  then  care  must  be  taken  not  to  interfere 
with  the  lachrymal  drainage  apparatus. 

§35.  When  the  palpebral  fissure  has  become  shortened  in 
consequence  of  the  shrinkage  of  the  conjunctival  sack,  and  of 
changes  in  the  curvature  of  the  tarsal  tissue,  the  condition  is 
called  blepharophimosis.  This  affection  is  nearly  always  due 
to  chronic  trachoma. 

In  order  to  extend  the  palpebral  fissure,  canthotomy  is  per- 
formed. This  consists  either  of  a  single  cut  through  the  outer 
canthus  with  one  clip  of  a  strong  pair  of  scissors,  or  the  cut 
is  followed  by  stitching  the  conjunctiva  into  the  corner  of  the 
wound  (canthoplasty).      In  the  former  case  care  must  be  taken 


Fig.  32. — Canthoplasty.    Showing  the  sutures  by  which  the  conjunctiva  is    stitched 
into  the  gap  produced  by  canthotomy. 

that  the  wound  does  not  heal  per  primam,  or  the  effect  will  be 
lost  again  altogether.  Even,  if  the  healing  per  primam  is  suc- 
cessfully prevented,  the  greater  part  of  the  effect  of  the  can- 
thotomy will  always  be  lost.  To  prevent  too  much  loss,  it  is 
best  to  undermine  the  conjunctiva  near  the  wound  with  fine 
scissors  and  then  to  sew  it  into  the  gap,  caused  by  the  can- 
thotomy. Three  sutures,  one  in  the  corner,  one  upwards  and 
one  downwards,  are  usually  sufficient.    (See  Fig.  32). 


62  OPHTHALMOL  OGY. 

In  severe  cases  of  blepharophimosis  Noyes  has  recommend- 
ed to  take  a  small  flap  from  the  temple  near  the  canthotomy- 
wound  and  to  twist  it  and  sew  it  into  the  gap. 

§36.  Wounds  of  the  eyelid,  which  involve  only  the  skin, 
or  the  skin  and  orbicularis  muscle,  heal,  as  a  rule,  readily  when 
aseptic.  Only  when  they  are  very  extensive,  may  they  give 
rise  to  ectropium  by  the  subsequent  contraction  of  the  scar- 
tissue. 

When  the  wound  extends  through  the  whole  thickness  of 
the  eyelid,  and  reaches  the  lid  margin,  it  usually  remains  more 
or  less  open,  the  wound-lips  become  covered  with  epithelium, 
and  a  traumatic  coloboma  of  the  eyelid  is  the  result.  Such  a 
coloboma  in  the  upper  eyelid  may,  if  extensive,  affect  the  eye 
injuriously  by  depriving  it  of  its  normal  protection,  as  in  the 
case  of  paralysis  of  the  orbicularis  muscle.  If  it  is  situated 
in  the  lower  eyelid,  it  forms  a  very  disagreeable  ectropium, 
over  which  the  tears  continually  trickle  down  the  cheek. 

By  paring  the  lips  of  the  coloboma  and  sewing  them  togeth- 
er, the  deformity  may  be  greatly  lessened,  and  in  most  cases 
entirely  cured,  except  for  a  small  notch  at  the  lid-margin. 

If  a  wound  severs  the  fibres  of  the  levator  palpebrae  supe- 
rioris  muscle,  a  traumatic  ptosis  must  result.  By  paring  the 
edge  of  the  torn  levator  muscle  and  stitching  it  to  the  tarsal 
tissue  the  ptosis  may  be  cured. 

Other  injuries  of  the  eyelids  have  to  be  treated  according 
to  general  surgical  principles. 

Sometimes  we  have  occasion  to  see  a  case  of  emphysema  of 
the  eyelids.  This  is  almost  always  due  to  an  injury  with  fracture 
of  the  inner  wall  of  the  orbit  (lamina  papyracea  ossis  ethmoi- 
dei  or  os  lachrymale),  establishing  a  communication  between 
the  nasal  cavity  and  the  areolar  tissue  of  the  orbit.  The  pa- 
tient must  be  guarded  against  blowing  the  nose  for  a  few  days. 
No  other  treatment,  except,  possibly,  a  compressive  bandage, 
will  be  required. 

Haemorrhages  into  the  tissue  of  the  eyelids,  aside  from  the 
unsightliness  due  to  them,  are  of  little  importance  and  become 
absorbed.  This  absorption  may  be  hastened  by  mild  massage. 
The  common  usage  of  applying  leaches  to  such    a  suggillated 


DISEASES   OF  THE  EYELIDS.  63 

lid  is  unreasonable,  and  by  causing  a  superficial  wound,  may 
l)e  the  means  of  infection  and  subsequent  suppuration. 

Burns  of  the  outer  surface  of  the  eyelid  are  very  frequently 
the  cause  of  ectropium  from  the  retraction  of  the  scar. 

Burns  of  the  conjunctival  surface  of  the  eyelid  and  eyeball 
will  mostly  result  in  an  attachment  between  the  two.  If  this 
is  only  partial,  it  is  called  symblepharon,  if  total  or  nearly  so, 
anchyloblepharon.  (See  Chapter  VII).  The  name  of  anchy- 
loblepharon  is  also  applied  to  a  union  of  the  lid-mkrgins  only. 


CHAPTER     IV.— DISEASES    OF    THE    LACHRYMAL 

APPARATUS. 

§37.  The  diseases  of  the  lachrymal  apparatus  must  be  di- 
vided into  diseases  of  the  organ,  which  secretes  the  tears,  the 
lachrymal  gland,  and  those  of  the  drainage  apparatus,  which 
consists  of  the  lachrymal  puncta  and  canaliculi  and  the  lach- 
rymal sack  and  duct. 

The  lachrymal  gland  in  the  normal  condition  secretes  con- 
tinually a  small  quantity  of  a  clear,  alkaline  fluid,  the  tears. 
An  excessive  secretion  of  tears  is  brought  about  by  nearly  all 
irritations  and  inflammations  of  the  membranes  of  the  eyeball 
and  eyelids,  by  the  presence  of  a  foreign  body  in  the  conjunc- 
tival sack,  and  under  the  influence  of  emotion,  as  in  crying. 

In  paralysis  of  the  trigeminus  nerve  the  secretion  of  tears 
may  be  stopped.  This  will  also  occur  when  from  some  cause 
the  lachrymal  gland  has  become  atrophied,  or  when  the  tear- 
ducts  have  become  obliterated. 

It  happens,  although  comparatively  seldom,  that  the  lachry- 
mal gland  becomes  the  seat  of  an  inflammatory  process.  This  is 
called  dakryo-adenitis,  and  is  usually  an  acute  inflammation.. 
It  is  sometimes  seen  to  attack  the  lachrymal  glands  of  both 
eyes  at  the  same  time.  In  some  cases  dakryo-adenitis  is  asso- 
ciated with  mumps. 

In  this  affection  the  gland  is  painful  to  the  touch;  it  swells 
and  the  temporal  half  of  the  upper  eyelid  becomes  oedematous. 
Soon  the  eyelid  swells  more,  and  can  no  longer  be  raised  suffi- 
ciently to  open  the  eye,  and  the  eyeball  is  pushed  gradually 
downwards  and  towards  the  nose,  and  somewhat  out  of  the 
orbit.  Any  movement  of  the  eye  in  an  upward  and  outward 
direction  is  attended  with  great  pain,  or  such  movements  may 
become  altogether  impossible.  It  may  now  be  possible  to 
feel  by  palpation  a  hard  tumor  in  the  outer  upper  part  of  the 
orbit  through  the    upper   eyelid,    or   even  to  see  it  protruding 


DISEASES  OF  THE  LACHRYMAL  APPARATUS.  65 

into  the  upper  fornix  of  the  conjunctiva,  if  the  swelling  per- 
mits the  upper  eyelid  to  be  everted.  Soon  the  tumor  becomes 
softer,  and  it  may  then  perhaps  be  possible  to  detect  fluctua- 
tion in  it.  When  not  interfered  with,  the  abscess  may  point 
through  the  upper  eyelid,  or  through  the  conjunctiva,  and  thus 
be  evacuated  into  the  conjunctival  sack.  The  wound  heals  quick- 
ly as  a  rule,  and  is  but  seldom  followed  by  a  fistula.  In  some 
cases  no  pus  is  formed,  and  the  inflammatory  symptoms  sub- 
side gradually  and  without  interference 

If  the  patient  is  afraid  of  the  knife,  all  that  can  be  done  in 
this  affection  is  to  apply  hot  fomentations  to  hasten  the  forma- 
tion and  evacuation  of  the  pus.  The  best  method  of  dealing 
with  a  dakryo-adenitis,  however,  is  to  make  an  early  incision 
into  the  swelling,  either  through  the  upper  eyelid,  or,  which  is 
preferable,  through  the  fornix  of  the  conjunctiva.  This  inci- 
sion should  be  followed  by  the  application  of  hot  fomentations 
and  the  instilla-tion  of  an  antiseptic  wash. 

A  chronic  non-suppurative  inflammation  of  the  lachrymal 
gland  has  been  observed,  but  it  is  extremely  rare. 

The  lachrymal  gland  is  sometimes  the  seat  of  a  neoplasm. 
Quite  a  number  of  tumors  of  the  lachrymal  gland  have  been 
described  by  the  older  authors,  and  their  histological  diagnoses 
vary  greatly,  and  are  little  creditable.  More  recent  investi- 
gations seem  to  show  that  the  tumors  of  the  lachrymal  gland 
are  usually  either  of  an  adenoid  or  an  epitheliomatous  char- 
acter. 

In  two  cases,  upon  which  I  had  occasion  to  operate,  I  found 
the  tumors  to  be  sarcomatous  and  to  consist  of  short  spmdle- 
cells. 

By  the  gradual  and  mostly  painless  swelling  of  the  lachry- 
mal gland  the  eyeball  is  more  and  more  pushed  downwards, 
towards  the  nose,  and  out  of  the  orbit,  and  the  movements  of 
the  eye  in  an  upward  and  outward  direction  become  restricted. 
As  the  upper  eyelid  is  usually  but  little  swollen,  although  ap- 
parently stretched  and  elongated,  and  the  pupil  generally  re- 
mains uncovered,  the  patient  may  be  greatly  troubled  by 
double  vision.  Soon  the  tumor  may  be  detected  by  palpa- 
tion; its  situation  in  the  upper  outer  part  of  the  orbit  and  its 
immobility  are  sufficient  to  settle  the    diagnosis.     Sometimes 


66  OPHTHALMOL  OGY. 

the  tumor  may  be  seen  in  the  upper  fornix  of  the  conjunctiva. 
The  vision  of  the  eye  on  the  affected  side  ultimately  becomes 
impaired,  and  may  even  be  totally  lost.  This  is  due  to  the 
stretching  of  and  the  impeded  circulation  in  the  optic  nerve, 
leading  to  cedema  of  the  optic  papilla,  optic  neuritis  and  sub- 
sequent fatty  degeneration  and  atrophy  of  the  optic  nerve. 

The  tumors  of  the  lachrymal  gland  seem  to  develop  mostly 
after  injuries.  There  is  nothing  to  be  done  in  the  way  of 
treatment  but  to  remove  the  tumor.  To  accomplis  this,  it  is 
best  to  make  an  incision  through  the  upper  eyelid,  over  the 
seat  of  the  tumor  and  parallel  with  the  upper  orbital  margin. 
When  the  tumor  has  been  once  reached  by  careful  dissection, 
it  should  be  separated  from  thesourrounding  tissues  by  means 
of  a  blunt  instrument,  such  as  the  handle  of  a  scalpel,  these 
tumors  being,  as  a  rule,  soft  and  easily  broken  into.  It  is,  of 
course,  best,  if  possible,  to  rem(»ve  the  newformation  as  a 
whole.  The  wound  usually  heals  with  great  rapidity,  and  the 
disagreeable  symptoms  disappear,  excepting,  of  course,  such 
impairment  of  vision  as  may  be  the  result  of  lesions  of  the 
optic  nerve.  Care  must  be  taken  not  to  cut  the  levator  palpe- 
brae  superioris  muscle,  an  accident  which  would  lead  to  ptosis 
of  the  upper  eyelid. 

Some  surgeons  prefer  to  attack  the  tumors  of  the  lachrymal 
gland  through  the  upper  fornix  of  the  conjunctiva,  after  hav- 
ing first  made  canthotomy. 

The  nature  of  these  growths  is,  it  appears,  but  rarely  very 
malignant,  and  local  relapses  are  seldom  observed,  except  in 
sarcoma  of  the  gland. 

I  have  recently  had  occasion  to  observe  a  case  of  adenoma 
of  the  accessory  lachrymal  gland  which  did  not  involve  the 
larger  gland  although  it  spread  deeply  into  the  orbit.  This 
tumor  caused  unceasing  pain,  spastic  contraction  of  the  eye- 
lids, some  exophthalmus  and  gradual  atrophy  of  the  optic 
nerve.  After  two  attempts  at  removal  with  preservation 
of  the  eyeball  relapses  took  place,  and  finally  a  thorough  re- 
moval could  only  be  accomplished  after  enucleation  of  the 
eyeball. 

In  rare  cases  a  cystic  distension  of  the  lachrymal  gland  or 
its    ducts    has   been  observed;  the  affection    has    been    called 


DISEASES  OF  THE  LACHRYMAL  APPARATUS.  67 

dakryops.  The  cystic  character  of  the  tumor  may  possibly  be 
detected  by  palpation  through  the  skin.  To  get  rid  of  it,  the 
whole  cyst-wall  should  be  removed,  or  shrinkage  may  be  in- 
duced by  injections  into  the  cyst,  or  by  in  some  manner  caus- 
ing an  artificial  adhesive  inflammation. 

§38.  We  come  now  to  the  diseases  of  the  drainage  ap- 
paratus. 

Eversion  of  the  lower  punctum  lachrymale  causes  the  tears 
to  run  down  over  the  cheek.  This  condition  is  called  epiphora, 
or  stillicidiiim.  It  may  be  brought  on  by  conjunctivitis  or 
blepharitis;  or  it  may  be  due  to  paresis  or  paralysis  of  the 
orbicularis  palpebrarum  muscle.  It  accompanies  all  forms 
of  ectropium  of  the  lower  eyelid,  and  may  be  due  to  various 
other  causes. 

Simply  slitting  the  canaliculus,  the  punctum  of  which  is 
everted,  suffices  usually  to  do  away  with  epiphora,  when  it  is 
not  due  to  paralysis  or  to  excessive  ectropium. 

Injuries,  especially  burns,  may  produce  closure  of  one  or 
both  puncta,  or  the  same  result  may  follow  chronic  inflamma- 
tion of  the  lid-margin;  cases  of  congenital  obstruction  of  the 
puncta  are  also  occasionally  met  with.  Spasmodic  contrac- 
tion of  Horner's  muscle  around  the  base  of  the  lachrymal 
papilla  may  constrict  a  canaliculus.  In  other  cases  the  presence 
of  a  foreign  body  may  cause  an  obstruction.  A  small  calculus, 
an  eyelash  caught  in  a  punctum,  threads  of  leptothrix  (a  vege- 
table parasite),  and  various  other  foreign  bodies  have  been 
found  in  such  cases.  In  some  cases  a  small  polypus  has  been 
found  growing  from  the  mucous  membrane  of  the  canaliculus 
and  plugging  it.  The  symptoms  due  to  the  obstruction  of  a 
canaliculus  (it  is  usually  a  lower  one)  by  a  foreign  body  are 
slight  pain,  swelling  and  epiphora.  Slitting  the  canaliculus 
and  removing  the  foreign  body  will  give  immediate  relief.  If 
the  punctum  is  only  contracted,  it  may  be  sufficient  to  over- 
stretch it  by  means  of  a  large  pin  or  small  conical  probe. 

Like  the  puncta,  one  or  both  canaliculi,  or  the  single  canal 
formed  after  their  union  before  entering  the  lachrymal  sack, 
may  become  closed  in  consequence  of  injuries  or  burns.  It  is 
then  usually  impossible  to  re-establish,  a  communication  with 
the  sack. 


68  OPHTHALMOL  OGY. 

The  mucous  membrane  of  the  lachrymal  sack  and  nasal 
duct  is  frequently  the  seat  of  inflammatory  processes.  These 
may  come  directly  from  inflammations  of  the  mucous  mem- 
brane of  the  nose,  or  they  may  originate  in  the  lachrymal 
sack  or  nasal  duct. 

§39.  The  most  frequent  form  of  inflammation  of  the  sack  is 
the  catarrhal  inflammation,  dakryo-cystitis  catarrhalis.  This  is  at- 
tended with  hypersemia,  swelling  and  hyper-secretion  of  mucus, 
so  that  the  entrance  into  the  nasal  duct  becomes  blocked  up, 
and  the  tears  cannot  pass  down  into  the  nose.  In  this  way 
the  lachrymal  sack  becomes  gradually  filled  with  fluid  and 
slightly  distended.  Lachrymation  follows,  and  the  eye  seems 
to  be  standing  in  water  nearly  all  the  time.  Then  the  lachry- 
mal caruncle  and  conjunctiva  become  inflamed,  and  sometimes 
blepharitis  ciliaris  is  developed. 

The  distended  lachrymal  sack  can  be  seen  as  a  small  swell- 
ing just  below  the  ligamentum  palpebrale  internum.  If  this 
distension  progresses,  this  swelling  may  reach  a  considerable 
size,  and  cause  the  skin  above  it  to  become  .  atrophic.  This 
condition  has  been  called  mucocele.  Even  the  lachrymal  bone 
may  yield  to  a  certain  extent  to  this  continued  pressure. 

By  pressing  upon  the  swelling  in  an  upward  direction,  it  is 
sometimes  possible  to  squeeze  the  contents  of  the  distended 
lachrymal  sack  into  the  conjunctival  sack,  and  the  mucus  will 
then  be  seen  oozing  out  through  one  or  both  of  the  lachrymal 
puncta  as  a  viscid,  grayish  or  clear  fluid.  Or  it  may  be  possible 
to  empty  the  lachrymal  sack  into  the  nose  by  pressing  upon 
it  with  a  downward  sweep. 

Dakryo-cystitis  catarrhalis  may  go  over  into  a  dakryo-cysti- 
tis purulenta,  or  the  latter  form  may  occur  as  a  primary 
affection.  Both  forms  of  inflammation  of  the  lachrymal  sack 
may,  furtherm<3re,  be  due  primarily  to  inflammation  and  con- 
sequent obstruction  of  the  nasal  duct,  causing  retention,  dis- 
intergration  and  infection  of  the  tear-fluid. 

In  dakryo-cystitis  purulenta  the  contents  of  the  sack  are 
of  a  yellow,  brownish  or  greenish  color,  and  are  often  very 
foetid.  The  symptoms  noticed  in  the  catarrhal  dakryo-cystitis 
are  present  in  an  aggravated  form,  and  there  is  often  consider- 
able pain. 


DISEASES  OF  THE  LACHRYMAL  APPARATUS,  69 

In  the  severe  forms  of  catarrhal  dakryo-cystitis  and  always 
in  purulent  dakryo-cystitis  a  free  opening  of  one  or  both  ca- 
naliculi  and  sometimes  even  of  the  conjunctival  wall  of  the 
lachrymal  sack  {Agnew)  must  be  made  in  order  to  be  able  to 
remove  its  contents.  The  little  operation  of  slitting  the  lach- 
rymal canaliculus  is  best  done  with  Weber's  curved  or  straight 
canaliculus-knife.  The  blunt  end  of  this  instrument  must  be 
pushed  through  the  canaliculus  into  the  lachrymal  sack  until 
it  has  reached  the  nasal  wall,  before  the  cut  is  made.  The  latter  is 
completed  while  the  knife  is  withdrawn.  If  there  is  no  obstruc- 
tion in  the  nasal  duct,  the  treatment  of  the  mucous  membrane 
of  the  lachrymal  sack  by  injections  of  solutions  of  bichloride 
of  mercury  i  to  2,500,  or  weaker,  boracic  acid  4  to  100,  and 
pyoktanine  i  to  500  will  soon  restore  the  normal  condition. 

It  is  well,  moreover,  to  direct  the  patient  to  use  gentle  mas- 
sage over  the  lachrymal  sack,  and  to  direct  him  to  pour  a  so- 
lution of  bichloride  of  mercury  into  the  conjunctival  sack, 
while  reclining  three  or  four  times  a  day. 

Purulent  dakryo-cystitis  sometimes  gives  rise  to  a  phlegmo- 
nous inflammation  of  the  subcutaneous  tissue  in  front  of  the 
lachrymal  sack.  This  causes  a  great  amount  of  sweUing,  heat 
and  redness  and  often  excruciating  pain.  The  eyelids,  and  the 
surrounding  tissue  (nose,  forehead  and  eyelids  of  the  fellow- 
eye)  may  become  so  much  swollen,  that  the  condition  very 
much  resembles  an  attack  of  erysipelas  and  is  not  infrequently 
confounded  with  it.  In  these  cases  it  is  utterly  impossible  to 
squeeze  out  the  contents  of  the  lachrymal  sack,  even  if  in 
spite  of  the  swelling  the  canaliculi  are  successfully  slit.  It 
therefore  may  become  necessary  in  such  a  case  to  make  an 
incision  through  the  skin  and  lachrymal  sack  down  to  the 
bone.  If  this  is  done  at  an  early  stage,  great  surffering  will 
be  prevented.  If  the  abscess  is  allowed  to  open  by  itself, 
lachrymal  fistula  may  be  the  result.  Injections  of  antiseptic  so- 
lutions, hot  fomentation,  gentle  massage  and  the  careful  removal 
of  all  further  discharge  should  follow  this  incision.  Although 
this  mode  of  operating  leaves  no  disfiguring  scar  and  it  is  not 
likely  to  be  followed  by  the  formation  of  a  lachrymal  fistula, 
it  is  better  to  empty  the  lachrymal  sack  by  slitting  the  canali- 
culi, whenever  this  is  possible.     In  a  great   many  cases,  how- 


70  OPHTHALMOLOGY. 

ever,  the  swelling  of  the  mucous  membrane  will  prevent  the 
emptying  even  when  the  canaliculi  are  slit. 

Dakryo-cystitis  may,  through  the  formation  of  scar-tissue, give 
rise  to  the  formation  of  lasting  folds  or  impassible  strictures  in 
the  lachrymal  sack  or  nasal  duct,  which  may  prevent  the 
tears  from  flowing  down  in  the  normal  way.  If  a  free  opening 
of  the  lachrymal  canaliculi  and  treatment  by  antiseptic  and 
astringent  injections  do  not  bring  the  mucous  membrane  back 
to  its  normal  condition,  we  must  sometimes  be  content  to  ad- 
vise the  the  patient  to  squeeze  out  the  contents  of  the  lachry- 
mal sack  as  often  as  it  becomes  filled,  if  possible,  into  the 
nose,  if  not,  into  the  conjunctival  sack. 

As  the  pus  coming  from  a  suppurating  lachrymal  sack  is 
known  to  be  very  infectious  and  to  cause  ulceration  or  ab- 
scess of  the  cornea,  especially  when  the  epithelium  of  this 
membrane  is  in  the  least  abraded,  the  frequent  instillation  of 
one  or  the  other  of  the  antiseptic  solutions  mentioned  above 
cannot  be  too  heartily  recommended. 

Both  forms  of  dakryo-cystitis  may  appear  acute  or  chronic. 

§40.  Dakryo-cystitis  may  be  a  primary  affection,  but  it  is 
nearly  always  caused  by  strictures  at  the  entrance  to  the  nasal 
duct  or  within  it,  and  consequent  retention  and  decomposition 
of  the  tear-fluid.  The  treatment  of  the  lachrymal  sack  must, 
therefore,  in  most  cases  be  conjoined  with  the  exploration  and 
dilatation  of  such  strictures  of  the  duct. 

If  the  symptoms  of  such  a  secondary  dakryo-cystitis  are 
not  very  severe,  it  will  suflfice  to  slit  one  canaliculus,  and  pref- 
erably the  upper  one.  As  soon  as  this  is  done,  it  is  well  to  en- 
ter the  sack  with  a  probe  and  explore,  whether  the  en- 
trance into  the  nasal  duct  is  free.  When  this  is  not  the  case, 
it  is  best  to  wait  a  few  days,  until,  under  the  use  of  cold  com- 
presses and  antiseptic  solutions,  the  inflammatory  swelling  has 
subsided.  Then  a  careful  exploration  of  the  lachrymal  sack 
and  the  nasal  duct  should  be  made  with  a  medium  sized 
probe  of  the  kind  devised  by  Bczvman,  made  of  silver,  or 
better,  aluminium.  I  generally  use  No.  3,  although  in  rare 
cases,  only  No.  2  or  even  No.  i  can  be  passed  at  the 
first  exploration.     There    is    more  danger   of  making  a   false 


niS EASES  OF  THE  LACHRYMAL  APPARATUS.  ■    71 

passage  with  very  small  probes,  and  they   should  therefore  be 
avoided.    (See  Fig.  33). 


Fig.  33. — Bowman's  probes  for  exploring  and  dilating  strictures  of  the  lachrymal 
duct. 

The  probing  is  done  in  the  following  manner:  The  patient 
being  directed  to  look  downwards  the  probe  is  gently  pushed 
through  the  slit  canaHculus,  into  the  lachrymal  sack  until  it 
reaches  the  opposite  (bony)  wall.  That  the  wall  is  reached, 
may  be  judged  by  the  feeling  of  solid  resistance,  and  by  the 
fact  that  movements  of  the  probe  in  a  horizontal  direction,  do 
not  cause  the  skin  of  the  upper  eyelid  to  become  wrinkled. 
During  this  first  step  of  the  little  manoeuvre,  it  is  well  to  draw 
the  eyelid  towards  the  temple.  As  soon  as  it  is  certain  that 
the  probe  has  reached  the  opposite  wall  of  the  lachrymal  sack 
this  traction  of  the  eyelid  must  be  released.  Now  sliding  the 
point  of  the  probe  down  along  the  wall  of  the  sack  it 
is  brought  into  a  nearly  vertical  position,  slanting  slightly  to- 
wards the  centre  of  the  forehead.  It  will  now  be  in  the  posi- 
tion to  be  slipped  down  into  the  nasal  duct.  This  last  step  is 
the  most  difficult,  and  ought  not  to  be  attempted  by  an  inex- 
perienced hand,  as  a  slight  pressure  in  the  wrong  direction 
may  cause  the  formation  of  a  false  passage,  which  will  not 
only  not  accomplish  the  wished  for  result  but  will  cause  great 
pain,  and  sometimes  profuse  haemorrhage  and  may  lead  to 
further  complications.  If  the  point  of  the  probe  has  once  en- 
tered the  nasal  duct  it  must  be  gently  pushed  down,  until  it  has 
passed  through  its  nasal  orifice.  We  must  make  sure  of  this 
latter  point,  as  obstructions  at  the  nasal  orifice  are  by  no  means 
rare.  While  the  probe  is  passing  down  the  nasal  duct  the 
feeling  of  resistance  will  give  us  an  exact  idea  where  a  strict- 


72  .  OPHTHALMOLOGY. 

ure  is  situated.  During  this  whole  procedure  no  undue  force 
must  be  used.  Often  when  an  obstacle  is  felt  a  twist  of  the 
probe  will  help  to  surmount  it.  If  the  lining  of  the  duct  is 
pierced  by  the  probe  the  bone  will  be  felt,  and  the  attempt  at 
probing  must  be  stopped  for  a  few  days. 

When  the  probe  has  been  successfully  passed,  it  is  best  to 
syringe  one  of  the  antiseptic  solutions  through  the  sack  and 
duct  after  its  withdrawal.  However,  only  a  gentle  pressure 
must  be  used,  and  even  this  must  be  stopped  at  once  if  the 
patient  complains  of  severe  pain.  I  have  seen  effusions  of  the 
injected  fluid,  probably  through  the  walls  of  the  lachrymal 
sack  into  the  adjacent  tissues,  which  were  as  alarming  in  their 
aspect  as  they  were  painful  to  the  patient. 

When,  by  probing,  we  have  located  one  or  more  strictures 
in  the  lachrymal  duct,  the  further  treatment,  aside  from  instill- 
ations of  an  antiseptic  solution,  consists  in  their  gradual  or 
forcible  dilatation. 

The  gradual  dilatation  is  in  most  cases  the  preferable  meth- 
od. After  a  probe  of  a  certain  diameter  has  been  introduced, 
it  is  allowed  to  remain  in  the  duct  for  ten  or  fifteen  minutes, 
and  then  gently  withdrawn.  When  this  probe  can  be  easily 
introduced,  a  little  larger  one  is  used,  and  again,  when  this 
can  easily  be  passed  down  through  the  stricture,  the  next 
larger  one  is  employed.  The  probing  should  be  done  at  first 
daily,  but  when  large  sized  probes  (No.  5  or  6),  pass  easily 
through  the  duct,  the  intervals  between  the  probing  should  be 
increased.  If  the  patient  has  pain  after  the  probing,  although 
no  false  passage  has  been  made,  cold  compresses  or  bathing 
will  give  relief,  and  the  pain  need  not  interfere  with  the  treat- 
ment; yet,  it  indicates  sometimes  that  too  large  a  probe  has 
been  used,  and  that  it  would  be  better  to  go  back  to  a  smaller 
size.  While  in  children  and  young  people  a  perfect  recovery 
is  generally  to  be  expected,  adults  and  older  people  are  less 
apt  to  be  perfectly  cured,  and  have  generally  to  be  probed 
again  from  time  to  time.  In  the  probing  and  dilatation  of 
strictures  of  the  nasal  duct,  I  have  found  the  preliminary  instil- 
lation or  injection  of  a  cocaine  solution  to  be  of  comparatively 
little  value,  although  I  always  employ  it.  When  necessary  the 
nasal  mucous  membrane  must  also  be  treated. 


DISEASES  OF  THE  LACHRYMAL  APPARATUS. 


73 


Forcible  detention  by  the  introduction  of  a  large  probe  at 
the  first  sitting,  does  not  seem  to  yield  as  good  and  lasting  re- 
sults as  does  the  gradual  distention;  it  is,  moreover,  extreme- 
ly painful. 

When  the  obstruction  of  the  nasal  duct  is  not  due  to  a 
stricture  in  the  mucuos  membrane,  but  to  an  affection  of  the 
surrounding  bone,  which  is  chiefly  caused  by  syphilis  or 
scrophulosis,  successful  probing  and  dilatation  of  the  duct  is 
but  rarely  possible 

If  there  is  a  fistula  of  the  lachrymal  sack,  this  will  heal 
without  any  special  treatment,  as  soon  as  we  have  succeeded 
in  restoring  the  caliber  of  the  duct,  so  as  to  allow  the  tears  to 
flow  down  through  it. 

Although  it  would  seem  scarcely  possible  to  break  off  a 
probe  in  the  nasal  duct,  I  must  give  warning  against  this  acci- 
dent, as  I  once  had  occasion  to  remove  such  a  broken  probe, 
left  in  the  duct  by  the  operator. 


Fig.  34. — (After  Gerlach)  Shows  the  manner  in  which  the  two  lachrymal  canaliculi 
form  one  larger  canal  before  entering  the  lachrymal  sack.  The  cupola  of 
the  lachrymal  sack  extends  considerably  higher  upward  than  the  point  of 
entrance  for  this  canal  is  situated. 


In  a  certain  percentage  of  cases  the  tears  will,  in  spite  of 
successful  probing  and  enlarging  of  the  formerly  closed  duct, 
refuse  to  be  drained  off  in  consequence  of  the  lack  of  elastic- 
ity of  the  walls  of  the  lachrymal   sack.     In  such  cases,  and  in 


74  .         OPHTHALMOLOGY, 

others  also,  in  which  for  any  reason  a  re-establishment  of  the 
drainage  from  the  lachrymal  sack  downwards  is  impossible, 
the  lachrymal  sack  can  be  obliterated.  This  may  be 
done  by  a  free  incision  into  it,  followed  by  the  destruc- 
tion of  the  mucous  membrane  by  actual  or  galvano-cau- 
tery,  or  by  the  use  of  caustic  drugs.  Care  must  always  be  taken 
to  destroy  all  of  the  mucous  membrane,  and  not  to  omit  cau- 
terizing well  up  in  the  cupola  of  the  lachrymal  sack.  (See 
Fig.  34).  The  healing  by  granulation  takes  place  in  from  two 
to  three  weeks.  The  scar  is  but  slightly  disfiguring,  and,  al- 
though the  epiphora  remains,  the  patients  are  greatly  benefitted 
by  the  operation.  The  lachrymal  sack  may  also  be  cut  out, 
instead  of  destroying  its  mucous  membrane. 

Instead  of  obliterating  the  lachrymal  sack,  Lawrence  advised 
the  removal  of  the  lachrymal  gland,  an  operation  which  seems 
to  grow  in  favor. 

The  lachrymal  caruncle  is  sometimes  the  seat  of  a  malig- 
nant tumor.  The  most  frequent  form  is  melano-sarcoma.  It 
must  be  removed  early;  the  operation  is  easily  performed. 


CHAPTER     v.— DISEASES     OF     THE     ORBIT. 

§41.  The  diseases  of  the  orbit  are  either  diseases  of  its 
bony  walls  and  periosteum,  or  they  concern  chiefly  its  con- 
tents. In  these  diseases  the  eyeball,  its  muscle,  and  the  optic 
nerve  are  as  a  rule  only  secondarily  affected. 

If  the  disease  of  the  orbit  causes  the  volume  of  its  contents 
to  become  increased,  the  eyeball  will  be  pressed  out  of  its 
normal  position,  and,  as  it  cannot  escape  in  any  other  direc- 
tion, it  will  be  pushed  out  of  the  orbit.  This  condition  is 
called  exophthalmos.  Exophthalmus  may,  furthermore,  be 
due  to  diseases  of  the  neighboring  cavities,  which  encroach 
upon  the  orbital  cavity,  or  to  tumors  of  the  eyeball  itself  or 
of  its  appendages.  The  exophthalmus  will,  in  a  general 
sense,  be  always  in  a  direction  opposite  to  the  swelling  in  the 
orbit  upon  which  it  depends  and  the  movements  of  the  eyeball 
will  be  restricted  in  the  direction  towards  this  swelling. 

§42.  Periostitis  of  the  ivalls  of  the  orbit  is  usuall/  confined 
to  a  part  of  the  orbital  margin,  and  it  seems  to  be  more  fre- 
quently observed  in  the  upper  and  outer  part,  than  at  any 
other  point.  In  the  beginning  the  patients  complain  of  spon- 
taneous pain,  and  soon  at  the  seat  of  this  pain  a  slight  immov- 
able swelling  appears,  which  is  very  sensitive  on  pressure. 
Gradually  the  swelling  increases,  the  conjunctival  vessels  are 
hyperaemic,  the  eyeball  is  slightly  pushed  forwards  and  to- 
wards the  opposite  side,  and  its  movements  in  the  direction  of 
the  swelling  become  restricted  and  painful.  The  localized 
swelling  and  pain  are  the  most  important  symptoms  for  the 
diagnosis. 

In  the  acute  form  of  periostitis  fluctuation  will  be  soon  felt, 
and  on  incision,  or  spontaneously,  pus  will  be  evacuated. 

If  the  acute  form  goes  over  into  the  chronic  form,  caries  or 
necrosis  of  the  bone  will  result,  and  fistulous  openings  through 

—75— 


76  OPHTHALMOLOGY. 

the  skin  will  allow  of  their  detection  with  a  probe.  The  prob- 
ing ought  to  be  done  very  carefully,  as  an  acute  inflammation 
of  the  orbital  tissue  might  follow. 

In  acute  periostitis  of  the  orbital  margin,  when  seen  at  a 
very  early  stage,  iced  compresses  and  leeches  may  sometimes 
suffice  to  effect  a  cure.  If  not,  an  incision  should  be  made  so 
as  to  give  a  free  opening  for  the  escape  of  the  pus. 

If  the  case  is  already  a  chronic  one,  matters  will  be  more 
complicated.  After  an  incision  has  been  made  down  to  the 
diseased  portion,  the  necrosed  bone  must  be  removed  or  the 
carious  parts  well  scraped  out.  In  these  chronic  cases  this 
operation  must  often  be  followed  by  a  plastic  one,  as  the  form- 
ation of  scars  bound  down  to  the  bone  often  causes  ectropium 
and  lagophthalmus.  Orbital  periostitis  of  deeper  seated  por- 
tions may  be  very  difficult  to  diagnose.  Usually  the  forma- 
tion of  an  abscess  gives  the  first  clew  to  the  real  trouble. 

In  rare  cases  a  chronic  form  of  the  orbital  periostitis  has 
been  seen  to  lead  to  thickening  of  the  bony  walls  and  conse- 
quent reduction  of  the  size  ofthe  orbital  cavity. 

Orbital  periostitis  is  most  frequently  the  result  of  an  injury. 
In  other  cases  it  is  due  to  a  strumous  or  syphilitic  diathesis, 
and  in  the  treatment  we  must,  of  course,  take  these  points  into 
consideration. 

§43.  Injuries  and  heavy  falls  may  cause  hcemorrhages  into 
the  orbital  tissues.  Such  haemorrhages  cause  sometimes  consid- 
erable exophthalmus  conjoined  with  paretic  symptoms  in  the 
muscles  of  the  eyeball.  The  blood  can  usually  be  seen,  as  it 
generally  infiltrates  the  ocular  conjunctiva,  and  in  some  cases 
raises  it  so  as  to  form  a  dark  red,  shining,  ring-shaped  elevation 
around  the  cornea-scleral  margin.  Such  a  haemorrhage  may, 
of  course,  be  due  to  the  rupture  of  blood-vessels  alone,  or  it 
may  be  complicated  by  fracture  of  the  bony  wall  of  the  orbit. 
It  may,  therefore,  be  a  comparatively  simple  affection,  and  its 
alarming  symptoms  may  disappear  after  a  short  time  without 
leaving  any  trace  behind.  In  the  other  case  it  may  give  rise 
to  rather  serious  complications,  and  especially,  as  the  fracture 
often  concerns  the  walls  of  the  optic  canal,  to  atrophy  of  the 
optic  nerve  and  consequent  blindness. 


DISEASES  OF  THE  ORBIT.  77 

§44.  Cellulitis  orbitcB,  phlegmonous  inflammation  of  the  or- 
bital tissue,  may  be  a  primary  affection,  or  it  may  be  due  to 
an  injury  with  or  without  the  subsequent  presence  of  a  foreign 
body;  it  may  be  caused  also  by  orbital  caries  or  necrosis,  es- 
pecially when  its  seat  is  far  back  in  the  orbit. 

Hyperaemia  and  oedema  of  the  conjunctiva,  oedema  of  the 
lids,  pain  in  the  orbit,  restriction  of  the  movements  of  the  eye- 
ball and  exophthalmus  are  the  first  symptoms  complained  of, 
and  may  be  attended  with  fever.  The  exophthalmus  is  most- 
ly in  a  forward  direction,  and  the  restriction  of  the  movements 
of  the  eyeball  is  then  general,  and  not  particularly  pronounced 
in  any  one  direction.  The  upper  eyelid  usually  swells  so  con- 
siderably that  it  is  impossible  for  the  patient  to  raise  it. 

The  pressure  and  traction  on  the  optic  nerve  may  cause 
oedema  of  the  optic  papilla  or  optic  neuritis,  with  attendant 
amblyopia.  Anaemia,  followed  by  atrophy  of  the  optic  nerve, 
or  detachment  of  the  retina,  may  also  be  caused  by  the  celluli- 
tis.    In  other  cases  sight  is  apparently  not  at  all  impaired. 

As  the  disease  progresses  pus  is  formed,  and  the  abscess 
may  point  either  in  the  eyelid  or  in  the  conjunctiva,  and  thus  a 
spontaneous  cure  may  take  place. 

In  rare  cases  the  pus  may  break  through  the  lamina  papy- 
racea  of  the  os  ethmoidei  into  the  nasal  cavity,  or  downwards 
into  the  antrum  of  Highmore,  or  even  upwards  into  the  cranial 
cavity;  causing  death  by  purulent  meningitis  or  abscess.  The 
inflammation  may,  moreover,  extend  to  the  eyeball,  and  cause 
plastic  irido-choroiditis,  or  purulent  irido-chroiditis  with  subse- 
quent shrinking  of  the  eyeball.  In  other  cases  the  cornea 
may  slough  away  in  consequence  of  the  impaired  nutrition 
and  exposure  due  to  the  exophthalmus. 

The  formation  of  pus  in  the  inflamed  tissue  is  occasionally 
very  slow,  and  yet,  the  impairment  of  sight  due  to  it  may  be 
comparatively  small.  I  once  had  occasion  to  see  a  case  of  or- 
bital cellulitis  five  weeks  after  the  first  symptoms  had  set  in, 
and  to  evacuate  the  pus  by  an  incision.  The  recovery  was 
rapid,  and  only  a  partial  atrophy  of  the  optic  nerve  remained 
behind. 

In  rare  cases  no  pus  is  formed,  and  the  inflammatory  symp- 
toms subside  again  after  a  short  period    of  existence.      The 


78  OPHTHALMOLOGY. 

manner  in  which  the  infection  of  the  orbital  tissue  comes 
about  when  it  is  not  caused  by  an  injury  or  caries,  or  erysipe- 
las is,  as  yet,  unknown.  In  one  case  which  I  have  seen  lately, 
the  affection  came  on  during  an  attack  of  typhoid  fever,  and 
may  have  been  due  to  the  specific  typhoid  micro-organism. 

With  regard  to  the  treatment,  first  of  all,  perfect  rest  and 
warm  applications  should  be  insisted  on.  If  after  a  few  days, 
the  symptoms  continue  unabated,  an  incision  should  be  made, 
whether  fluctuation  can  be  felt  or  not.  If  pus  is  found,  it  will 
escape  through  the  incision,  and  the  eyeball  will  gradually  re- 
cede to  its  normal  position  in  the  orbit.  If  no  pus  is  there,  or 
even  if  the  knife  has  not  reached  it,  the  bleeding  and  subse- 
quent oozing  of  serous  fluid  will  reduce  the  tension  of  the  tis- 
sues, and  thus  give  relief.  The  wound  must,  of  course,  be  kept 
open  until  all  symptoms  have  disappeared,  and  the  warm  ap- 
pHcations  should  also  be  kept  up. 

The  incision  into  the  orbital  tissue  is  best  made  through  the 
conjunctiva.  If  this  is  impossible,  it  may  be  done  through  the 
lid.  A  narrow  knife  should  be  used  and  great  care  be  taken 
not  to  wound  the  eyeball  or  the  optic  nerve.  It  is  sometimes 
very  difficult  to  reach  the  pus-cavity,  and  it  is  then  preferable  to 
make  further  exploration  with  a  blunt  instrument.  The  wound 
heals  very  readily,  and  if  the  optic  nerve  and  eyeball  have  re- 
mained intact,  perfect  recovery  may  be  obtained  in  the  course 
of  a  few  days.  If  the  incision  and  evacuation  of  the  pus  are 
followed  by  an  injection  of  an  antiseptic  solution,  no  undue 
pressure  must  be  exerted. 

It  is  well  to  know  that  symptoms  which  resemble  very  much 
those  of  orbital  cellulitis  may  be  due  to  thrombosis  of  the 
cavernous  or  of  the  longitudinal  sinus.  In  the  latter  cases 
however,  the  affection  usually  concerns  both  orbits  and  their 
contents,  and,  moreover,  the  cerebral  symptoms  will  help  to 
make  the  diagnosis  clear. 

§45.  After  tenotomy  of  one  of  the  external  muscles  of  the 
eyeball  for  strabismus  an  inflammation  oj  Tenon's  capsule  is 
sometimes  observed.  Although  the  pain  and  swelling,  and 
the  visible  inflammatory  symptoms  are  somewhat  like  those  of 
an  orbital  cellulitis,  a  mistake  is  hardly  possible,  since  the  in- 


DISEASES  OF  THE  ORBIT.  79 

flammation  of  Tenon's  capsule  {Tenonitis,  as  it  is  inappropri- 
ately called),  causes  only  a  comparatively  slight  protrusion 
of  the  eyeball. 

A  small,  red  swelling  is  in  these  cases  at  first  observed  near 
the  incision  made  in  the  tenotomy.  It  is  immovable,  but  may 
be  fluctuating,  and  is  covered  by  hyperaemic  and  oedematous 
conjunctiva.  This  swelling  may  increase  in  size  and  gradually 
extend  around  the  whole  of  the  periphery  of  the  cornea.  The 
movements  of  the  eyeball  are  painful  and  somewhat  restricted, 
but  only  in  consequence  of  the  pain,  for  the  eyeball  may  be 
moved  in  all  directions.  The  upper  eyelid  is  slightly  oedemat- 
ous. The  fluctuation  is  due  to  serous  fluid  within  Tenon's 
space.  This  serous  form  of  inflammation  of  Tenon's  capsule 
may  accompany  chronic  iridochoroiditis,  and  it  often  compli- 
cates cases  of  acute  purulent  panophthalmitis. 

In  the  uncomplicated  cases  of  serous  inflammation  of 
Tenon's  capsule,  the  fluid  may  be  evacuated  by  an  incision  or 
aspiration.  Otherwise  iced  compresses,  rest  anci  subcutane- 
ous injections  of  pilocarpine  are  useful. 

Emphysema  of  the  orbital  tissue  (and  eyelids)  is  sometimes 
observed  in  consequence  of  a  fracture  of  the  lamina  papyracea 
of  the  OS  ethmoidei;  also  occasionally,  in  consequence  of  in- 
juries of  the  lachrymal  bone,  or  of  the  bony  walls  of  the  nasal 
duct  from  forced  dilatation  of  this  passage  for  the  cure  of  an 
obstruction. 

§46.  The  orbit  is  not  infrequently  the  seat  of  neoplasms, 
which  may  be  either  benign  or  malignant  in  character. 

Cystoid  formations,  when  met  with  in  the  orbit,  usually  lie 
under  the  upper  eyelid  near  to  and  above  the  outer  angle  of 
the  palpebral  fissure,  and  outside  of  the  funnel  formed  by  the 
external  muscles  of  the  eyeball.  These  cysts  contain  an  oil- 
like fatty,  or  mucoid  fluid,  of  an  amber  or  brownish  tint.  Their 
walls  may  become  firmly  adherent  to  the  periosteum  of  the 
orbit  or  even  to  the  eyeball  itself,  and  are  often  very  vascular. 
They  grow  slowly  and  may  bring  about  a  partial  atrophy  of 
the  eyelid  by  their  continued  pressure.  They,  moreover,  dis- 
place the  eyeball  and  may  cause  a  noticable  exophthalmus 
with  attendent   double-vision,  and  with   the  other   symptoms 


80  OPHTHALMOLOGY. 

which  depend  upon  continued  stretching  and  impaired  nutri- 
tion of  the  optic  nerve. 

True  dermoid  cysts,  and  echinococcus  cysts  have  also  been 
observed  in  this  locality. 

Such  cysts  must  be  removed,  and,  of  course,  if  possible 
enucleated  in  toto.  In  doing  so  care  must  be  taken  not  to 
breack  the  cyst-sack,  or  to  injure  the  eyeball  or  its  external 
muscles. 

Of  vascular  tumors  both  angiomata  and  teleangiectatic 
growths  are  found  in  the  orbit. 

A  number  of  primary  epithelial  cancers  of  the  orbital  tissue 
have  been  described,  yet  it  seems  that  the  tumors  of  this  tissue 
are,  as  a  rule,  not  of  an  epithelial,  but  on  the  contrary  of  the 
connective-tissue  type.  Thus  we  find  round  and  spindle-cell 
sarcoma,  melano-sarcoma,  fibrosarcoma,  myxosarcoma,  cysto- 
sarcoma  and  cylindroma  of  the  orbital  tissue. 

I  had  once  occasion  to  examine  a  large  orbital  tumor,  re- 
moved fram  a*  negro  woman,  with  preservation  of  the  eyeball^ 
by  the  late  Dr.  Darby,  of  New  York.  It  proved  to  be  a  leiomy- 
oma, and  consisted  almost  wholly  of  organic  muscular  fibres. 
No  similar  case  has  been  anywhere  reported,  and  I  suppose 
the  tumor  originated  from  the  organic  muscular  fibres  lying 
in  the  orbital  tissue. 

The  symptoms  of  all  these  different  forms  of  orbital  tumors 
are  similar,  and  the  most  prominent  one  is  always  the  exoph- 
thalmus.  To  this  may  be  added  intercurrent  inflammatory 
symptoms,  and,  again,  all  the  symptoms  referable  to  the  optic 
nerve  and  to  the  cornea,  as  we  observe  them  in  cases  of  ex- 
ophthalmus  due  to  a  newformation  in  the  lachrymal  gland  or  to 
orbital  cellulitis. 

The  tumor  may  frequently  be  detected  by  palpation  and 
does  not,  of  course,  move  when  the  eyeball  is  moved. 

Such  a  newformation  must  be  removed,  as  soon  as  detected. 
As  long  as  it  can  be  done,  an  attempt  should  be  made  to  pre- 
serve the  eyeball.  If  a  complete  removal  of  the  tumor  cannot 
be  accomplished  without  it,  the  eyeball  must  be  sacrificed,  and 
in  some  cases  the  whole  of  the  orbital  tissue  will  have  to  be 
cleaned  out  in  order  to  save  the  patient's  life. 

In  case  the  eyeball  has  been  removed  with  the  tumor,  a  sug- 


DISEASES  OF  THE  ORBIT.  81 

gestion  made  by  Green  is  very  valuable,  indeed.  It  is,  to  fur- 
ther remove  the  lid-margin,  the  palpebral  conjunctiva  and  the 
tarsal  tissue,  and  sew  the  eyelids  together.  The  eyelids  heal 
promptly  together  and  thus  form  a  permanent  cover,  which 
protects  the  deeper  tissues  from  injurious  influences. 

Another  class  of  orbital  tumors  spring  from  its  bony  walls 
in  the  forms  of  osteoma  or  periosteal  sarcoma. 

The  contents  of  the  orbit  may,  moreover,  be  invaded  by 
tumors  originating  in  the  neighboring  cavities,  especially  the 
nasal  cavity  and  the  antrum  of  High  more;  the  symptoms  will 
be  much  the  same  as  in  cases  of  primary  orbital  tumors. 

Pulsating  exophthalmus,  as  well  as  exophthalmic  goitre 
{Basedow's,  Graves'  disease)  will  be  spoken  of  in  Chapter 
XXIII. 


CHAPTER    VL— MINOR    MANIPULATIONS    IN    THE 
TREATMENT    OF    EYE    DISEASES. 

§47.  Continued  cold  applications  to  an  eye  are  best  made  by 
means  of  a  piece  of  light  linen,  which  after  having  been  cooled 
either  in  cold  water,  or  ice  water,  or  directly  on  ice,  is  laid 
upon  the  closed  eye.  This  Hnen  should  be  folded  several 
times,  because  it  will  then  keep  its  temperature  for  a  longer 
time,  and  a  second  one  ought  always  be  kept  cooling  while  the 
first  one  is  lying  on  the  eye.  As  soon  as  the  linen  on  the  eye 
no  longer  causes  a  cooling  sensation,  it  should  be  changed. 
The  time  in  which  this  will  have  to  be  done,  will,  of  course, 
depend  on  various  circumstances.  With  children  it  may  be 
necessary  to  fasten  the  linen  with  a  simple  bandage. 

Care  must  always  be  taken  to  wring  the  linen  dry  before  ap- 
plying it,  and  not  to  allow  any  cold  water  to  trickle  down  and 
enter  the  ear.  This  may  be  the  better  guarded  against  by 
putting  some  oiled  cotton  into  the  ears. 

Instead  of  the  linen  a  very  small  ice-bag  may  sometimes  be 
used.  Yet  its  weight  must  be  so  small  as  not  to  be  felt  dis- 
agreeably. A  continued  current  of  cold  water  through  tubing 
forming  a  coil  over  the  eye  may  also  be  employed. 

When  cold  bathing  only  is  required  from  time  to  time,  this 
is  best  done  by  gently  pressing  a  cooled  sponge  or  linen  rag 
against  the  closed  eye.  This  may,  however  be  replaced  with 
great  advantage  by  an  eye-douche.  A  quart  or  more  of  cold 
water  may  thus  be  allowed  to  flow  against  the  eye  from  a  mod- 
erate hight  through  a  very  fine  rose. 

Opening  the  eyes  under  water  should  be  avoided. 

In  cases  of  phyctaenular  keratitis,  with  great  dread  of  light 
and  spasmodic  entropium,  it  is  of  great  value  to  apply  a  sud- 
den cold  bath  to  the  whole  face.  This  is  best  done  by  plung- 
ing the  child's  face  into  a  basin  of  cold  water  and  by  holding 
it  there  until  it  struggles  for  breath. 

This  procedure  may  be  varied  by  holding  the  child  over  a 

—82— 


MINOR  MANIPULATIONS.  83 

basin  and  directing  a  moderately  strong  stream  of  cold  water 
full  in  his  face  through  a  rather  course  rose. 

Interrupted  hot  applications  are  best  made  in  thjs  same  way 
as  cold  ones,  or  by  allowing  steam  from  an  atomizer  to  be 
thrown  against  the  closed  lids. 

Dry  heat  may  sometimes  be  indicated,  and  may  be  best  ap- 
plied by  means  of  the  Japanese  hot-box  or  in  default  of  this 
by  means  of  little  bags  containing  a  light  material,  such  as 
bran  which  will  retain  the  heat  for  some  time.      ♦ 

Leeches  must  never  be  applied  either  to  the  eyeball  itself  or 
to  the  eyelids.  The  best  place  for  the  application  of  leeches 
in  eye-affections  is  the  temple,  or,  more  accurately,  the 
space  between  the  outer  angle  of  the  palpebral  fissue  and  the 
line,  where  the  hair  begin  to  grow. 

This  is  also  the  best  place  for  the  application  of  Hoeurte- 
loufs  artificial  leech. 

Any  discharge  from  the  palpebral  conjunctiva  should  be 
gently  and  carefully  removed.  What  sticks  to  the  eye-lashes 
and  the  lachrymal  caruncle,  when  semi-fluid,  can  be  easily 
wiped  away  by  the  use  of  a  soft,  moist  sponge  or  absorbent 
cotton. 

When  the  discharge  is  dried  up  and  hard,  it  must  first  be  well 
soaked  by  bathing  with  warm  water.  It  can  then  be  removed 
by  brushing  the  eye-lashes  back  and  forth  in  a  horizontal  di- 
rection with  a  sponge,  or  still  better  with  a  dry  towel.  After 
the  eyelashes  and  lid-margins  have  thus  been  cleansed,  the 
conjunctival  sack  must  be  inspected  and  every  film  of  coagu- 
lated discharge  be  removed.  This  may  be  done  by  gently 
wiping  it  off  with  a  very  warm  sponge  or  some  absorbent  cot- 
ton, or  better  yet  by  a  gentle  stream  of  a  4%  boracix  acid  so- 
lution, which  is  allowed  to  flow  over  the  eye. 

How  to  evert  the  eyelids  for  examination  of  the  palpebral 
conjunctiva  and  fornix,  has  been  described  in  Chapter  II. 

§48.  For  the  instillation  of  medicated  fluids  into  the  con- 
junctival sack,  it  is  best  to  use  a  dropping  tube,  or  dropping 
glass.  Where  this  cannot  be  procured  a  clean  teaspoon  may 
answer  the  purpose. 

As  infection  may  undoubtedly  be  carried  from  one  patient 
to  the  other  by  means  of  a  dropping  tube,  every  care  should 


84  OPHTHALMOL  OGY. 

be  had  to  use  it  only  when  in  an  aseptic  condition.  In 
hospital-practice  every  patient  should  have  his  own  dropping 
tube  or  glass.  In  order  to  instill  the  fluid  into  the  conjunctival 
sack,  the  eyelids  should  be  held  apart  with  the  other  hand  and 
the  lower  eyelid  be  drawn  down  sufficiently  to  allow  the  drop 
to  enter,  while  the  patient  is  directed  to  look  upward.  Medi- 
cated fluids,  which  have  no  astringent  or  caustic  quality,  and 
whose  effect  is  to  be  reached  by  absorption,  such  as  solutions 
of  a  mydriatic  or  miotic  drug,  should,  if  possible,  be  allowed 
to  drop  directly  upon  the  cornea,  as  they  are  thus  absorbed 
more  readily.  The  drop  must  not  fall  from  any  appreciable 
hight,  should  not  be  cold,  and  must  not  be  allowed  to  be 
washed  out  at  once  by  the  tears.  Whenever,  therefore,  it  is 
difficult  to  make  such  instillations  or  when  instillations  are  to 
be  made  by  the  inexpert,  it  is  best  to  direct  the  patient  to  lie 
on  his  back  and  to  hold  his  eyelids  apart  for  some  time  after 
the  instillation  has  been  made. 

Before  applying  any  astringent  or  caustic  remedy  to  the 
conjunctiva,  the  rule  should  be  to  instill  a  few  drops  of  a 
cocaine  solution  into  the  conjunctival  sack.  By  this  means 
the  patient  will  be  saved  a  considerable  amount  of  suffering, 
and  we  are  much  better  able  to  make  our  application  for  the 
very  reason  that  the  patient  does  not  dread  it. 

Astringent  solutions  should  be  applied  by  means  of  a  moder- 
ately large  camel's  hair  brush,  dipped  into  the  fluid  and  then 
drawn  across  the  conjunctival  surface  of  the  everted  eyelid. 
It  usually  suffices  to  apply  them  to  the  lower  eyelid.  If,  in 
spite  of  the  cocaine,  pain  and  irritation  are  very  annoying  after 
such  an  application,  the  patient  should  be  directed  to  bathe 
the  closed  eyes  for  some  time  with  cold  water. 

After  having  been  used  the  brushes  must  be  washed  and 
kept  in  a  solution  of  bichloride  of  mercury  (i  to  5,000)  for 
hours,  or  best  until  shortly  before  they  are  used  again  the 
next  day. 

The  application  of  caustic  solutions  should  always  be  made 
by  the  surgeon  himself.  When  making  such  an  application 
the  cornea  must  never  be  left  unguarded.  It  is  therefore  best 
to  treat  each  diseased  eyelid  separately  with  a  brush.  While 
the  caustic  solution  is  brushed  upon  the   inner  surface  of  the 


MINOR  MANIPULATIONS.  85 

everted  upper  eyelid,  the  patient  looking  down,  the  lower  eye- 
lid is  gently  drawn  upward,  so  as  to  cover  the  cornea  perfectly. 
By  a  similar  manoeuvre  the  upper  eyelid  is  made  to  protect  the 
cornea  while  the  lower  one  is  treated.  As  soon  as  the  appli- 
cation is  made,  the  brush  should  be  dipped  into  a  bowl  of 
water,  held  by  the  patient  under  his  chin,  and  the  superfluous 
caustic  be  washed  off  with  it.  It  is,  of  course,  impossible  to 
neutralize  the  primary  effect  of  the  caustic  by  washing,  so 
there  need  be  no  hesitation  in  using  plenty  of  water.  The 
application  of  caustic  fluids  should  not  be  repeated  until  the 
superficial  eschara  caused  by  the  last  application  is  cast  off, 
which  takes  place  in  from  20  to  24  hours.  It  is  therefore  best 
to  use  these  remedies  only  once  in  24  hours  and  to  make  the 
application  at  about  the  same  hour  every  day,  preferably  in 
the  fore-part  of  the  day  or  at  least  not  in  the  evening. 

By  quick,  intelligent  manipulation  with  the  brush,  the  effect 
of  the  caustic  application  can  be  nicely  graded,  and  even  to  a 
certain  extent  localized. 

Sulphate  of  copper,  in  substance,  the  sovereign  remedy  in 
trachoma,  should  also  be  applied  by  the  surgeon  himself.  For 
this  purpose  a  large  crystal  should  be  trimmed  thin  and  per- 
fectly smooth  and  mounted  in  a  crayon  holder  to  make  its 
handling  easier.  No  sharp  edge  or  roughness  must  be  allow- 
ed to  remain  before  the  application,  and  the  surgeon  should 
therefore  examine  the  crystal  every  time  before  using  it,  and 
dry  it  well  after  the  treatment  of  every  eyelid.  The  applica- 
tion to  the  conjunctiva  should  be  made  very  gently  by  simply 
drawing  the  crystal  once  across  the  part  to  be  treated,  and 
the  conjunctiva  should  then  be  washed  off  at  once  with  a 
brush  dipped  in  water.  All  rubbing  and  prolonged  contact, 
producing  a  caustic  effect,  is  to  be  avoided.  What  is  wished  for 
is  only  irritation  and  stimulation,  and  not  the  "burning  off"  of 
the  granules.  It  is,  therefore,  a  good  rule,  to  aim  at  touching 
the  diseased  parts  as  lightly  as  possible,  rather  than  the  reverse. 
As  the  seat  of  the  granules  is  mostly  in  the  fornix,  the  surgeon 
must  be  careful  to  apply  the  copper  crayon  to  this  part  especially. 
In  treating  the  fornix  of  the  upper  eyelid,  it  is  necessary,  there- 
fore, to  go  high  up  under  the  everted  eyelid,  and  in  doing  so  it 
is  best  to  lay  the  crystal  against  the  lower  eyelid,  so  as  to  drag  it 


86  OPHTHALMOLOG\. 

along  and  protect  the  cornea,  while  the  copper  is  shifted  up- 
wards. Treating  the  fornix  of  the  lower  eyelid  is,  of  course, 
very  much  easier,  since  it  can  be  fully  exposed.  All  these 
little  manipulations  must  be  performed  with  great  delicacy 
and  care,  in  order  to  obtain  the  best  possible  result.  In  this 
point  lies  the  secret  of  the  different  results  obtained  by  differ- 
ent physiciaus  with  the  sulphate  of  copper  in  substance. 

Nitrate  of  silver  in  substance  or  in  the  form  of  the  mitigated 
stick  is  best  altogether  avoided. 

Some  remedies  are  best  applied  to  the  eye  in  the  form  of 
ointments.  The  common  advice  to  simply  smear  a  little  of  the 
ointment  into  the  eye  or  on  the  inner  surface  of  the  lower  eye- 
lid, is  not  sufficient,  as  only  very  little  of  the  ointment  will 
reach  the  part  it  is  chiefly  intended  for,  namely,  the  cornea. 

The  best  method  of  applying  an  ointment,  if  it  is  not  fluid 
enough  to  be  brushed  upon  the  inner  surface  of  the  upper  eye- 
lid, is  to  take  a  little  on  the  end  of  a  blunt  probe,  to  bring  it 
between  the  separated  eyelids,  and  then  to  close  the  lids  quick- 
ly while  the  carrier  is  withdrawn.  If  this  does  not  succeed 
the  upper  eyelid  must  be  everted  and  the  probe  with  the  oint- 
ment be  brought  upwards  between  it  and  the  eyeball.  Then 
the  probe  is  withdrawn,  and  the  eyelid  returning  to  its  normal 
position  wipes  off  the  ointment. 

In  the  cocainized,  eye  it  is  possible  to  directly  apply  the 
ointment  to  the  cornea,  as  no  reflex-spasm  takes  place. 

It  is  then  well  to  gently  rub  the  ointment  with  the  eyelids 
all  over  the  eyeball  in  circular  and  radiating  movements,  ex- 
erting all  the  time  a  slight  pressure.  These  movements  have 
the  effect  and  value  of  massage,  and  are  especially  to  be  rec- 
ommended in  corneal  affections. 

For  the  inspergation  of  medicinal  powders ,  such  as  calomel  or 
iodoform,  into  the  conjunctival  sack,  it  is  best  to  make  use  of 
a  small,  dry  camel's  hair  brush.  This  is  lightly  dipped  into 
the  powder,  the  eyelids  are  separated  with  the  fingers  of  the 
other  hand,  and  the  powder  is  snapped  off  the  brush  into  the 
conjunctival  sack. 

As  the  discharge  in  most  forms  of  inflammation  of  the  con- 
junctiva is  contagious,  a  great  many  efforts  have  been  made  to 
perfectly  isolate  a  healthy  eye,  so  long  as  its  fellow  continues 


MINOR  MANIPULATIONS.  87 

diseased.  Yet  most  of  these  contrivances  are  very  annoying 
and  after  all  useless,  as  perfect  isolation  is  almost  impossible. 
Absolute  cleanliness  and  the  free  use  of  antiseptic  solutions, 
particularly  to  the  as  yet  unaffected  eye,  according  to  my  ex- 
perience, are  at  least  as  good  preventives  as  any  appliance  for 
isolating  a  healthy  ese,  especially  when  the  patient  remains  in 
such  a  position  that  no  discharge  from  the  diseased  eye  can 
run  across  the  bridge  of  the  nose  into  the  healthy  one. 

To  isolate,  however,  a  child  suffering  from  one  of  the  serious 
forms  of  conjunctivitis  (purulent,  gonorrhoeal,  diphtheritic  or 
trachomatous  conjunctivitis)  from  other  children,  is  highly  to 
be  recommended,  nor  should  such  a  child  ever  be  allowed  to 
go  to  school.  This  is  often  allowed  when  children  suffer  from 
trachoma  or  from  chronic  purulent  conjunctivitis,  but  it  is  to 
be  absolutely  condemned  as  bad  practice. 

§49.  Wild  hairs,  ingrowing  eye-lashes,  are  easily  pulled  out, 
when  they  are  large  and  well  pigmented,  with  appropriate  for- 
ceps. But  often  the  most  annoying  ones  are  very  thin  and  fine, 
and  almost  unpigmented.  To  detect  these  is  then  sometimes 
rather  difficult,  and  is  best  done  by  placing  the  patient  side- 
ways to  the  light,  and  then  looking  along  the  lid-margin, 
which  should  be  slightly  drawn  away  from  the  eye.  Alter- 
nately applying  the  lid-margin  to  the  eyeball  and  lifting  it  off 
will  help  greatly  in  the  detection  of  such  eye-lashes,  since  they 
will  raise  the  tear-fluid  somewhat  before  being  drawn  away  by 
the  eversion  of  the  lid-margin.  Great  care  must  be  taken  to 
extract  the  cilia  with  the  root  and  not  to  brake  them  off. 

The  whole  procedure  is,  however,  of  but  little  value,  and,  to 
afford  a  temporary  relief  only,  must  be  repeated  again  and  again. 
The  patients  should  therefore  be  persuaded  to  have  an  opera- 
tion for  trichiasis  performed.     (See  Chapter  III). 

The  removal  of  small  foreign  bodies  from  the  conjunctival 
sack  is,  as  a  rule,  a  very  simple  affair,  as  the  foreign  bodies  lie 
for  the  most  part  loosely  on  the  conjunctiva.  They  may  be 
removed  from  the  everted  eyelid  by  means  of  a  moist  camel's 
hair  brush  or  a  piece  of  soft  linen.  In  the  lower  conjunctival 
sack  they  are  usually  found  lying  in  the  fornix.  In  the  upper 
conjunctival  sack  they  lie  most  frequently  in  the  small  depres- 


88  OPHTHALMOL  OGY. 

sion  just  above  the  inner  edge  of  the  lid-margin.  When  one 
small  foreign  body  has  been  thus  removed,  the  surgeon  should 
scan  the  whole  conjunctival  sack  once  more,  and,  if  necessary, 
sweep  the  upper  conjunctival  sack  as  high  up  as  possible  with 
a  camel's  hair  brush,  moistened  with  a  boracic  acid  or  sublim- 
ate solution.  When  the  foreign  body  is  not  easily  detected 
by  its  color,  it  may  be  necessary  to  draw  the  aseptic  finger 
gently  over  the  surface  of  the  palpebral  conjunctiva  and  thus 
to  satisfy  ourselves  of  its  seat  and  perfect  removal. 

For  a  careful  inspection  of  the  eyes  of  children,  it  is  often 
necessary,  in  spite  of  the  previous  instillation  of  cocaine,  to 
separate  the  eyelids  by  means  of  Desmarres'  or  some  other 
kind  of  lid  retractors.  During  their  use  great  care  must  be 
taken  not  to  exert,  nor  to  let  the  patient  exert,  any  pressure  on 
the  eyeball.  It  is  therefore  best  to  insert  the  retractor  for  the 
upper  eyelid  first.  This  is  done  by  everting  the  lid-margin 
slightly  by  dragging  the  skin  upwards  with  the  index  finger  of 
one  hand  and  slipping  the  retractor  under  the  eyelid  with  the 
other  hand,  all  the  time  pulling  the  eyelid  slightly  away  from 
the  eyeball.  The  insertion  of  the  retractor  for  the  lower  eye- 
lid is  much  easier,  but  must  be  done  in  the  same  manner. 

To  insert  and  remove  a  wire-speculum  to  hold  the  eyelids 
apart  during  an  operation  on  the  eyeball  requires  the  same 
delicacy.  The  branch  for  the  upper  eyelid  in  most  cases 
should  be  inserted  first,  while  the  branches  are  held  tightly  to- 
gether, and  the  same  precautions  are  to  be  observed  as  in  in- 
serting  the  lid-retractor.  While  this  is  being  done  the  patient 
is  directed  to  look  downwards.  Then,  while  the  patient  looks 
upwards,  the  branch  for  the  lower  eyelid  is  inserted,  and  the 
two  branches  are  allowed  to  separate.  When  the  speculum  is 
removed,  the  branch  for  the  lower  eyelid  is  first  taken  out, 
while  the  branches  are  pressed  together,  and  then  the  one  for 
the  upper  eyelid.  In  doing  this  the  eyelids  are,  with  the  spec- 
ulum, gently  pulled  away  from  the  eye-ball,  so  as  to  avoid  any 
pressure  upon  it. 

The  insertion  of  a  wire-speculum  is,  of  course,  necessary, 
or  at  least  of  great  advantage,  in  all  important  operations  on 
the  eye-ball,  yet  the  general  practitioner  should  also  be  famil- 
iar with  it,  as  he  is  frequently  called  upon  to  remove  small  for- 


MINOR  MANIPULATIONS.  89 

eign  bodies  from  the  cornea.  Some  patients,  in  spite  of  cocaine 
instillations,  cannot  keep  their  eyes  open  voluntarily  and  the 
lids  must  be  forcibly  held  open  in  order  to  be  able  to  accom- 
plish the  desired  end. 

After  the  speculum  has  been  properly  adjusted,  the  con- 
junctiva and  subjacent  tissue  are  grasped  with  the  fixation-for- 
ceps near  the  cornea,  and  best  near  the  lower  corneo-scleral 
margin,  as  the  eyeball  will  instinctively  fly  upwards  to  avoid 
the  instrument  used  for  the  removal  of  the  foreign  body.  The 
latter  should  not  be  a  sharp  instrument,  especially  in  the 
hands  of  the  unpracticed  operator.  A  bent  needle,  or  a  some- 
what blunt  minute  spud  or  gouge,  are  the  most  appropriate  in- 
struments for  this  purpose. 

Care  must  be  taken  not  to  injure  the  neighboring  parts  of 
the  corneal  tissue,  and  to  attack,  as  far  as  possible,  the  foreign 
body  only.  The  unexperienced  operator,  however,  had  better 
keep  his  hands  from  this  apparently  trifling,  but  sometimes 
rather  difficult,  little  operation. 

When  inserting  an  artificial  eye^  it  is  best  to  follow  the  rule 
for  inserting  the  speculum,  that  is  to  insert  it  first  under  the 
upper  eyelid  while  the  patient  looks  downwards,  and  again, 
when  removing  it,  to  lift  it  first  out  of  the  lower  conjunctival 
sack  while  the  patient  looks  upwards.  The  patient  should  be 
directed  to  bend  his  head  over  a  bed  or  pillow,  when  remov- 
ing the  artificial  eye  himself,  until  he  has  acquired  sufficient 
skill  inthe  manipulation  to  accomplish  it  without  tear  of  let- 
ting the  artificial  eye  fall. 

§50.  For  closing  the  eye  or  both  eyes  after  an  operation 
or  injury,  it  has  been  and  still  is  the  custom  with  a  number  of 
oculists  to  use  a  bandage  of  flannel,  linen,  gauze,  or  some 
such  material.  Such  a  bandage  is  from  two  to  three  yards 
long,  and  from  one  and  a  half  to  three  inches  wide.  After 
the  eye  has  been  nicely  padded  with  some  light  and  elastic 
aseptic  material,  the  end  of  the  rolled  up  bandage  is  placed 
over  the  ear  on  the  affected  side  in  a  horizontal  position,  and 
the  bandage  unrolled  toward  the  forehead  and  wound  around  it. 
After  it  has  passed  above  the  ear  on  the  opposite  side  the  roll 
of  bandage  is  lowered  so  as  to  reach  the  face  again   from  be- 


90  OPHTHALMOLOG  Y. 

low  the  ear  on  the  affected  side,  and  again  unrolled  upwards 
across  the  affected  eye  towards  the  other  side'of  the  head,  where 
it  may  be  fastened  with  pins  or  tied  with  braid  sewed  to  the 
end,  or  several  more  such  tours  may  be  made.  In  this  man- 
ner varying  degrees  of  pressure  may  be  applied  to  the  eye.  In 
the  same  way  both  eyes  may  be  bandaged,  and  to  afford  more 
security  against  the  slipping  of  the  bandage  a  cross-piece  may 
be  added  going  over  the  top  of  the  head.  To  prevent  the 
possibility  of  any  unforseen  pressure  little  wire  masks  (Prouf) 
may  be  applied  to  the  eye.     (See  Fig.  35). 


Fig.  35.— Wire  Mask. 

The  advantage  of  such  or  similar  bandages  have  been  decid- 
edly overestimated.  In  spite  of  all  care,  they  slip  often  and 
cause  themselves  the  pressure  upon  the  affected  eye,  for  the 
prevention  of  which  they  have  been  applied.  Tliey  are  in  the 
way  of  free  movements  of  the  face  and  head,  just  on  that  very 
account.  In  warm  weather  they  are  hot  and  fret  the  patient. 
When  they  are  not  perfectly  aseptic  they  may  form  a  source 
of  infection  and,  however  well  applied,  they  will  admit  air, 
which  means  increased  possibility  of  infection. 

A  neatly  applied  adhesive  plaster  is  free  from  all  these  ob- 
jections and  is  preferable. 


MINOR  MANIPULATIONS.  91 

The  ideal  closing  of  an  eye,  however,  according  to  my  own 
experience,  consists  of  a  pad  of  absorbent  cotton  moistened 
with  an  antiseptic  solution,  which  is  shaped  so  as  to  fill  out 
the  orbital  depression  near  the  nose  and  to  cover  the  whole  of 
the  eyelids,  and  is  held  in  place  by  a  piece  of  adhesive  plaster 
reaching  from  the  cheek  to  the  forehead,  and  from  the  nose  to 
the  temple.  This  plaster  can  be  applied  in  such  a  manner  that 
it  does  not  press  on  the  eye,  not  even  during  mastication,  and 
makes  an  air-tight  closure.  If  the  dr>mess  of  the  cotton  on 
the  second  or  third  day  is  felt  disagreeably  by  the  patient,  a 
little  moistening  of  a  narrow  strip  allows  of  the  insertion  of  a 
dropping  tube  to  re-moisten  the  cotton  with  an  antiseptic  so- 
lution. Such  a  plaster  allows  of  all  reasonable  freedom  of 
motion,  remains  aseptic  and  is  a  boon  to  the  patient.  The  ad- 
hesive quality  must,  of  course,  be  of  the  best,  so  that  even  the 
perspiration  will  not  loosen  it. 

§51.  This  is  probably  the  best  place  to  give  a  few  hints  for 
the  use  of  general  practitioners  who  are  asked  to  assist  in  an 
eye-operation.  The  tenderness  and  delicacy  of  movements 
required  in  the  operator  should  also  be  possessed  by  the  as- 
sistant. The  observance  of  a  few  simple  special  rules  by  the 
assistant  will  make  his  services  valuable,  while  no  assistant 
would  be  preferable  to  one,  not  observing  these  rules. 

As  good  Hght  is  absolutely  and  especially  required  in  every 
eye-operation,  the  first  rule  for  the  assistant  is,  to  keep  out  of 
the  light,  and,  as  perfect  freedom  of  movement  is  necessary 
for  the  operator,  the  second,  and  no  less  important  rule,  is  to 
keep  out  of  his  way.  Both  rules  are  usually  best  followed,  if 
the  assistant  stands  on  the  side  of  the  patient  opposite  to  the 
operator.  As  the  operator  will,  as  a  rule,  be  ambidexter, 
the  assistant  ought  to  be  so  too.  If,  for  instance,  the  assistant 
is  required  to  hold  the  eye  steady  during  a  certain  stage  of  an 
operation,  he  should  hold  it  with  the  right  hand  when  the 
operator  uses  his  left,  and  vice  versa,  at  least  when  they  stand 
on  opposite  sides  of  the  patient.  To  have  the  eye  steadied 
by  a  trusty  hand  is  of  such  great  assistance  to  the  operator, 
that  he  would  not  be  likely  to  do  without  it,  when  it  is  to  be 
had.     Yet,  a  hand  that  is  not  trusty,  is  worse  than  none. 

In  order  to  steady  the  eyeball  the  conjunctiva  is  grasped  with 


92  OPHTHALMOLOGY. 

the  fixation  forceps  near  the  cornea-scleral  margin,  and  as  di-, 
rectly  as  possible  at  right  angles  to  the  direction  of  an  incision, 
and  the  teeth  of  the  forceps  are  inserted  into  the  tissue  as  deep 
as  possible.  The  forceps  should  always  be  held  so  that  the 
thumb  can  at  any  moment  press  on  its  spring-catch  and  open 
it  without  any  further  movement.  It  is  best  to  use  forceps 
without  a  catch.  No  traction  and  no  pressure  must  be  exerted. 
If  the  globe  must  be  turned  downwards  by  the  assistant 
this  is  not  to  be  done  by  pulling  downwards  on  the  fixation  for- 
ceps, but  by  rotating  the  eyeball  around  its  horizontal  axis, 
by  slightly  raising  the  hand  that  holds  the  forceps  and  lowering 
the  part  attached  to  the  globe  gently  towards  the  lower  fornix. 
This  little  manipulation,  if  awkwardly  done,  may  ruin  an  eye. 

It  is  sometimes  necessary  for  the  removal  of  a  small  foreign 
body  from  the  cornea,  or  the  division  of  the  lens-capsule,  etc., 
to  have  the  field  of  operation  well  illuminated  by  artificial  light. 
To  do  this  we  use  a  large  magnifying  lens,  which,  of  course 
must  be  held  by  the  assistant.  It  seems  an  easy  matter  to 
throw  sufficient  light  with  such  a  lens  upon  the  field  of  opera- 
tion, yet,  it  requires  careful  attention  on  the  part  of  the  assis- 
tant to  do  it  satisfactorily,  as  the  position  of  the  lens  must  be 
changed  with  almost  every  movement  of  the  eyeball  or  head 
of  the  patient.  The  assistant  should  therefore  not  divide  his 
attention  between  this  and  anything  else  of  interest  during 
the  operation,  or  it  may  happen  that  the  operator  will  find 
himself  suddenly  with  a  dark  field  of  operation  before  him. 

When  the  operation  is  a  bloody  one,  as,  for  instance,  an 
operation  on  the  eyelids,  or  a  strabisum  operation,  or  the  enu- 
cleation of  an  eyeball,  the  assistant  should  be  prompt  in  wip- 
ing away  the  blood.  A  careful  assissant  will,  by  wiping 
quickly  after  every  cut  that  draws  blood,  enable  the  operator 
to  work  rapidly  and  never  in  the  dark. 

It  is  always  best  to  wipe  the  blood  away,  not  to  soak  it  up, 
as  is  frequently  done,  by  pressing  a  sponge  or  absorbent  cot- 
ton on  the  bleeding  surface.  On  the  contrary  all  pressure 
should  be  carefully  avoided,  especially  in  operations  upon  the 
eyeball  itself. 

Lastly,  the  assistants  hands  should  should  be  made  aseptic 
before  the  operation  is  begun. 


CHAPTER    VII.-DISEASES    OF    THE    CON- 
JUNCTIVA. 

§52.  Hypercemia  of  the  conjunctival  blood-vessels  is  fre- 
quently observed,  especially  in  the  conjunctiva  of  the  eyelids. 
It  may  be  more  pronounced  in  one  part  than  in  another,  but  it 
always  shows  least  in  the  fornix.  The  color  of  the  hyperaemic 
parts  is  a  bright  red,  almost  scarlet.  In  hyperaemia  of  the 
eyeball  we  have  seen  (see  Chapter  II),  that  it  is  necessary  to 
distinguish  between  hyperaemia  of  the  ocular  conjunctiva,  and 
that  which  lies  more  deeply  and  has  its  seat  in  the  sclerotic. 

When  hyperaemia  of  the  conjunctiva  has  existed  for  some 
time,  the  fornix,  and  later  on  the  ocular  conjunctiva,  show  a 
slightly  cedematous  condition.  Later  the  papillae  of  the  con- 
junctiva become  enlarged,  and  protrude  slightly  above  the 
general  surface  of  the  conjunctiva,  especially  near  the  fornix. 

Hyperaemia  of  the  conjunctiva  may  be  due  to  some  irrita- 
tion as  for  instance,  a  lack  of  moisture  in  the  air  of  a  heated 
room,  electric  light,  or  too  much  glaring  light  from  any  source; 
to  the  presence  of  small  foreign  bodies  in  the  conjunctival 
sack;  it  accompanies  coryza,  and  it  may  even  originate  in  the 
strain  incident  to  an  error  of  refraction.  It  can,  furthermore, 
be  symptomatic  both  in  certain  more  serious  forms  of  eye- 
diseases,  and  in  other  disorders. 

Patients  suffering  from  hyperaemia  of  the  conjunctiva  com- 
plain of  a  dry,  heated  feeling,  especially  in  the  evening.  Their 
eyes  get  easily  tired,  and  there  is  slight  photophobia  and  lach- 
rymation. 

The  removal  of  the  irritating  cause,  which,  however,  it  is 
sometimes,  quite  difficult  to  find,  will  be  followed  by  the  disap- 
pearance of  the  hyperaemia.  If  there  is  an  error  of  refraction  or 
accommodation,  its  correction  by  suitable  glasses  will  have 
the  desired  effect. 

When  the  hyperaemic  condition  of  the  conjunctiva  has  be- 

—93— 


94  OPHTHALMOLOGY. 

come  chronic,  the  instillation  of  4%  boracic  acid  solution,  or 
even  a  1-2%  solution  of  sulphate  of  zinc  will  be  useful.  One  of 
these  remedies  may  be  combined  with  systematic  cold  bathing 
or  the  cold  eye-douche.     Some  patients  prefer  hot  bathing. 

A  special  form  of  very  marked  hyperaemia  of  the  conjunc- 
tiva, which  is  chronic  and  recurrent,  is  due  to  syphilis.  This 
will  yield  only  to  antisyphilitic  treatment.  Local  applications 
in  these  cases  are  not  only  useless  but  they  do  not  even  seem 
to  be  agreeable. 

§53.  When  hyperaemia  of  the  conjunctival  blood-vessels  is 
combined  with  an  increased  and  abnormal  secretion  of  the 
conjunctival  mucous  membrane,  we  have  to  deal  with  conjunc- 
tivitis. 

The  protection  afforded  by  the  eyelashes  and  the  reflex 
movements  of  the  lids  do  not  suffice  to  shield  the  moist  sur- 
faces of  the  cornea  and  conjunctiva  from  the  adhesion  of  num- 
erous micro-organisms  which  floating  in  the  air  come  con- 
tinually in  contact  with  the  open  eye.  It  is,  therefore,  not 
astonishing  that  the  normal  conjunctival  sack  even  contains  a 
large  variety  of  micro-organisms  which  are  of  a  seemingly 
non-pathogenic  character.  Although  it  not  as  yet  proven  for 
some,  it  is  most  likely  that  all  the  different  forms  of  conjunc- 
tivitis are  due  to  the  presence  and  products  of  some  kind  of 
micro-organism.  This  explains  the  fact  long  well  known, 
namely,  that  the  discharges  from  the  conjunctiva  are  con- 
tagious, that  is  that  any  form  of  conjunctivitis  may  be  trans- 
mitted by  the  discharge,  if  it  reaches  another  eye  in  a  moist 
state,  and  perhaps  also  when  dry.  The  degree  of  inflamma- 
tion produced  in  an  eye  by  such  an  infection  may  vary  con- 
siderably, according  to  its  susceptibility.  Other  conjunctivae 
may  be  altogether  immune  against  the  special  infection.  The 
epidemic  and  endemic  appearance  of  some  of  the  forms  of 
conjunctivitis  is  now  better  understood. 

The  discharge  from  an  eye  suffering  from  any  form  of  con- 
junctivitis being  contagious,  the  physician  must  never  forget 
to  guard  the  family  of,  or  attendants  on  a  patient  against  con- 
veying any  of  the  discharge  to  their  own  eyes  by  means  of 
the  fingers,    towels,  handkerchiefs,  etc.     Constant  and  careful 


DISEASES  OF  THE  CONJUNCTIVA.  95 

removal  and  disinfection,  or  destruction  by  fire,  of  any  dis- 
charge, and  absolute  cleanliness  and  antisepsis  must  be  in- 
sisted upon. 

It  is  best,  therefore,  in  all  forms  of  conjunctivitis  to  give  the 
patients  an  antiseptic  solution  with  which  to  flush  the  conjunc- 
tival sack  three  or  four  times  during  the  day,  aside  from  the 
local  treatment  applied  by  the  surgeon  himself. 

Eyes  suffering  from  any  form  of  conjunctival  inflammation 
must  never  be  bandaged. 

Acute  catarrhal  conjunctivitis,  is  characterized  by  hyper- 
aemia  and  oedematous  swelling  first  of  the  palpebral  and  later 
of  the  ocular  conjunctiva,  accompanied  sometimes  by  small 
subconjunctival  ecchymoses.  Gradually  the  papillae  of  the 
conjunctiva  become  enlarged  and  give  it  an  uneven,  even  vel- 
vety appearance.  The  eyelids,  especially  the  upper  one,  swell 
so,  that  the  papebral  fissure  appears  smaller.  Photophobia 
and  lachrymation  are  but  seldom  absent  and  pain  or  great  dis- 
comfort is  a  prominent  symptom.  The  patients  often  locate 
the  latter  in  the  outer  or  inner  angle  of  the  palpebral  fissure 
and  insist  upon  it  that  they  have  a  forgein  body  in  the  con- 
junctival sack.  These  symptoms  are  accompanied  or  soon 
followed  by  the  secretion  of  mucus  or  muco-pus.  This  is  not 
secreted  in  large  quantity,  and  coagulates  easily.  It  will  be 
found  in  yellowish  flocks  within  the  conjunctival  sack,  espe- 
cially in  the  lower  and  upper  fornix  and  upon  the  lachrymal 
caruncle.  Some  of  it  usually  adheres  to  the  eyelashes. 
During  sleep  the  eyelashes  of  the  opposite  eyelids  by  the 
dried  up  mucus  are  glued  together  and  the  patient  is  unable 
to  open  his  eyes  on  waking.  This  often  gives  rise  to  excoria- 
tions along  the  lid-margins.  At  the  outer  angle  of  the  palpe- 
bral fissure  the  skin  is  often  found  to  be  red  and  painful,  and 
easily  torn,  which  is  due  to  maceration  by  the  tears. 

In  some  cases  this  complex  of  symptoms  comes  on  very 
violently  and  is  attended  with  so  much  oedema  and  discharge, 
that  the  appearance  resembles  an  attack  of  acute  purulent  in- 
fection. This  form  is  often  endemic  or  even  epidemic,  and  has 
been  more  frequent  than  ever  since  the  epidemic  of  influenza 
has  made  its  appearance. 

The  real  living  contagium  of  catarrhal  conjunctivitis  has  not 
yet  been  found. 


96  OPHTHALMOLOGY. 

Although  a  "cold"  has  probably  little  to  do  with  the  causation 
of  an  attack  of  conjunctivitis,  it  is  usually  attributed  to  it.  The 
possibility,  that  germs  that  live  in  the  conjunctival  sack  with- 
out being  able  to  do  harm  as  long  as  it  is  normal,  may,  when 
direct  chilling  of  the  lids  and  conjunctiva  takes  place,  become 
enabled  to  do  harm,  cannot  be  denied.  We  have  analogues 
to  such  an  occurrence,  for  instance,  in  the  production  of  pneu- 
monia by  the  pneumococci  which  have  lived  in  the  air-passages 
without  doing  harm,  until  they  are  given  a  chance,  so  to 
speak,   "by  a   cold." 

Catarrhal  conjunctivitis  may  give  rise  to  the  formation  of 
small  ulcers  of  cornea  at  its  conjunctival  margin.  When  some 
of  these  coalesce,  a  larger  crescentic  ulcer  may  result.  ^  They 
disappear,  as  the  catarrhal  inflammation  of  the  conjunctiva 
disappears  and  usually  need  no  special  attention  although  they 
are  sometimes  quite  painful.  If  necessary  atropine  or  eserine 
may  be  instilled. 

Aside  from  a  frequent  washing  of  the  conjunctival  sack  with 
an  antiseptic  solution,  the  application  of  a  nitrate  of  silver  so- 
lution (i  to  lOo)  by  the  surgeon  is  the  remedy  on  which  most 
reliance  can  be  placed  to  cure  this  disease.  This  application 
should  be  made  once  in  eyery  twenty-four  hours.  As  soon  as 
the  nitrate  of  silver  touches  the  conjunctiva,  it  gives  rise  to  the 
formation  of  a  superficial  eschara,  which  is  followed  by  an  in- 
crease of  all  symptoms  for  a  period  of  hours  varied  according 
to  the  individuality  of  the  case  and  the  degree  of  thorough- 
ness of  the  application.  Cocaine  may  reduce  the  pain,  but 
not  prevent  it.  Gradually  the  irritation  decreases  and  the 
cast-off  eschara  may  be  found  lying  in  the  folds  of  the  con- 
junctival sack  as  a  mucoid  string,  and  be  removed.  Regener- 
ation of  the  epithelium  now  takes  place  gradually  and  is 
finished  in  about  twenty-four  hours  after  an  application  of  the 
nitrate  of  silver  solution.  It  is  then,  that  a  new  application 
should  be  made. 

This  treatment  may  be  aided  in  and  the  patient's  comfort  be 
greatly  increased  at  first  by  the  continued,  later  on  by  the  in- 
terrupted  use  of  cold  cloths  or  iced  compresses  to  the  eye. 
The  photophobia  is  sometimes  so  disagreeable  that  it  is  best  to 
order  the    patient  to  wear  smoked  glasses.     To   prevent  the 


DISEASES  OF  THE  CONJUNCTIVA.  97 

lashes  from  sticking  together  white  vaseline  should  be  applied 
to  the  edges  of  the  lids  at  night. 

Acute  catarrhal  conjunctivitis  may  pass  over  into  the  chronic 
form.  In  the  latter  the  symptoms  are  all  considerably  amelior- 
ated, and  the  patients  may  be  able  to  attend  to  their  duty  all 
day  while  in  the  evening  they  are  particularly  annoyed  by  the 
affection. 

The  eyes  become  easily  tired  and  "sleepy"  and  complaint 
is  often  made  of  a  feeling,  as  if  dust  or  sand  were  lying  in  the 
conjunctival  sack. 

Another  sensation,  as  if  the  lids  were  stuck  to  the  eyes  and 
could  not  be  opened,  is  also  a  common  complaint. 

During  sleep  some  discharge  collects  at  the  inner  angle  of 
the  palpebral  fissure  or  adheres  to  the  eyelashes,  and  often  the 
eyelashes  are  found  stuck  together  in  the  morning. 

Like  chronic  pharyngitis  on  rhinitis,  chronic  catarrhal  con- 
junctivitis is  one  of  the  most  frequent  affections,  and  while 
some  patients  will  never  mind  it,  others  will  try  all  means  to 
get  rid  of  it.  Relapses  are  extremely  frequent,  still  beyond 
the  annoyance  caused  by  it,  the  disease,  but  seldom  gives  rise 
to  any  more  serious  sequels.  In  rare  cases  corneal  ulcers  may  be 
seen  due  to  it.  When  it  is  combined  with  blepharitis  ciliaris,  as 
it  mostly  is,  it  aids  this  disease  in  the  production  of  ectropium. 

Chronic  catarrhal  conjunctivitis  does  not  always  start  with 
an  attack  of  acute  catarrhal  conjunctivitis.  It  may  come  on 
insidiously  and  is  then  due  to  the  frequent  irritations  of  the 
conjunctiva  by  means  of  bad  or  dry  air,  heat,  dust,  chemical 
vapors  and  similar  admixtures  to  the  air.  It  may  also  proceed 
from  a  stoppage  of  the  tear  passage  (lachrymal  conjunctivitis) 
or  from  the  presence  of  a  tumor  in  the  lid  or  conjunctiva,  like 
pterygium,  and  in  a  great  many  cases  from  strain  due  to  an 
error  of  refraction  or  accommodation. 

In  chronic  catarrhal  conjunctivitis  the  use  of  a  nitrate  of 
silver  solution  is  but  rarely  indicated.  The  affection  is  re- 
duced in  its  more  disagreeable  symptoms  or  cured  by  the  ap- 
plication of  milder  astringents.  A  one  per  cent,  solution  of 
sulphate  of  zinc  is  the  best  remedy  in  the  average  case.  This 
may  be  brushed  over  the  conjunctiva  once  or  twice  a  day.  In 
mild  cases   the  washing  of  the  conjunctival  sack  with  a  four 


98  OPHTHALMOLOGY, 

per  cent,  solution  of  boracic  acid  may  be  sufficient.  To 
these  remedies  may  be  added  cold  or  hot  bathing,  according 
to  the  patient's  feeling.  Other  remedies  recommended  are 
alum,  tannine  and  tincture  of  opium.  To  prevent  the  lashes 
from  becoming  glued  together  during  sleep,  the  edges  of  the 
lids  should  be  greased  with  white  vaseline. 

§54.  Actite  purule7it  conjunctivitis  (blennorrhoea  of  the  con- 
junctiva, blennorrhceal  or  gonorrhceal  -conjunctivitis),  is  proba- 
bly always  due  to  the  infection  of  the  conjunctiva  with  the 
gonococcus  of  Neisser.  These  micro-organisms  are  found  in 
the  epithelial  cells  and  in  the  discharge  and  therefore  get  into 
an  eye  either  by  direct  contact,  or  indirectly  through  the  air, 
or  by  means  of  towels  from  another  purulent  eye,  or  from  a 
patient  suffering  from  gonorrhoea. 


Fig.  36. — (After  Saemisch).     Hypertrophied  papillae  of  the  conjunctiva  in  blennor- 
rhceal conjunctivitis. 

After  the  infection  has  taken  place  and  a  varying  period  of 
incubation  has  passed,  the  eyelids  become  hot  and  swollen. 
This  oedema  of  the  lids  may  very  rapidly  become  so  consider- 
able that  the  patient  cannot  open  the  eye.  At  the  same  time 
a  watery  discharge,  intermixed  with  flocks  of  yellow  muco- 
pus,  makes  its  appearance  and  glues  the  lashes  together.  As 
these  symptoms  increase  in  severity,  the  conjunctiva  of  the 
lids  swells  more  and  more,  so  that  when  the  lids  are  everted 
the  enlarged  and  engorged  papillae  form  several  ridges,  with 
deep  fissures  between  them.  (See  Fig.  36).  The  feelings  of 
heat,  weight  and  pain  grow  very  distressing.  Gradually  the 
discharge  changes  to  a  thick  cream-like  yellow,  sometimes 
greenish  pus,  which  continually  pours  down  from  the  eye  n 


DISEASES  OF  THE  CONJUNCTIVA.  99 

corrodes  the  skin  of  and  near  the  lids.  At  this  stage  the  oc- 
ular conjunctiva  is  also  considerably  swollen  and  hyperaemic 
and  oedematous,  and  forms  a  shining  elevated  ring  around  the 
periphery  of  the  cornea  (chemosis).  With  the  profuse  secre- 
tion the  necrotic  superficial  epithelium  is  cast  off.  In  conse- 
quence of  this  the  superficial  bloodvessels  are  easily  ruptured, 
and  considerable  haemorrhage  may  ensue  when  the  lids  are 
everted. 

As  the  formation  of  pus  becomes  more  profuse,  the  sub- 
jective symptoms  grow  less  severe.  This  is  due  particularly 
to  the  decrease  of  the  swelling  of  the  lids  and  conjunctiva 
which  now  takes  place.  If  left  to  itself  the  disease  will  run 
its  course  in  from  four  to  six  weeks.  The  swelling  and  dis- 
charge will  gradually  decrease  and  may  finally  disappear  al- 
together, or  a  chronic  blennorrhoea  may  remain  behind. 

In  severe  cases  patches  of  infiltration  are  formed  in  the  pal- 
pebral conjunctiva,  which,  as  they  contain  no  blood,  are  yel- 
lowish white  and  hard  and  appear  like  diphtheritic  patches. 
In  others  the  exudation  forms  membranes  on  the  surface  of 
conjunctiva  as  they   are  seen  in   croupous  conjunctivitis. 

The  impaired  nutrition  of  the  cornea,  as  well  as  the  direct 
infection  from  the  pus,  in  which  it  is  continually  bathed,  fre- 
quently cause  corneal  affections.  These  are  usually  infiltra- 
tions and  ulcers,  which  are  especially  destructive  when  occurr- 
ing during  a  purulent  conjunctivitis.  The  ulcers  begin  for  the 
most  part  near  the  corneo-scleral  margin,  and  may  travel 
around  the  whole  periphery  of  the  cornea  (ring-shaped  ulcer). 
They  may,  however,  appear  in  any  part  of  the  cornea.  If  the 
disease  is  not  brought  promptly  under  control,  the  ulceration 
leads  to  perforation  of  the  cornea,  prolapse  of  the  iris,  and 
eventually  to  the  total  destruction  of  the  eyeball. 

Acute  purulent  conjunctivitis  is  frequently  seen  in  the  eyes 
of  the  newly-born  (blennorrhoea  neonatorum).  The  etiology  and 
course  of  the  disease  is  the  same  as  in  the  adult.  In  both  the 
infants  and  the  adults  the  attacks  vary  in  intensity,  but  it  can 
be  stated  that,  comparatively  speaking,  the  infant's  eyes  can 
stand  the  ravages  of  this  disease  better  than  those  of  the 
adult. 

In  both  the  disease  is  caused  by  the  specific  virus.     It  lies 


100  OPHTHALMOLOGY, 

in  the  hands  of  the  general  practitioner  who  delivers  a  woman 
to  prevent  the  possibility  of  the  development  of  the  blennor- 
rhcea,  and  on  him  solely  must  fall  the  blame,  if  he  fails  to  do 
so.  We  know  that  not  only  virulent  gonorrhceal  discharges  of 
the  vagina,  bub  also  the  mucoid  discharge  of  a  chronic  vagi- 
nitis is  to  be  dreaded.  It  is,  therefore,  best  to  make  it  a 
routine  practice  in  all  cases  of  childbirth  to  apply  such  pre- 
ventative treatment  as  gives  security  against  blennorrhoea  neo- 
natorum. That  this  can  be  done  most  effectively  may  be 
gleaned  from  the  statistics  of  larger  lying-in  institutions. 
While  formerly  in  some  of  them  blennorrhoea  neonatorum  hap- 
pened in  from  fifteen  to  thirty  per  cent,  of  the  cases,  these  same 
institutions  have  been  able  to  reduce  the  percentage  to  con- 
siderably below  one  per  cent.  Of  all  the  blind  people  about 
one-third  have  been  blinded  for  life  by  this  same  disease. 
These  figures  may  by  intelligence  and  care  be  wiped  out  alto- 
gether. The  simplest  method  of  prevention  is  that  of  Credky 
and  consists  of  the  instillation  of  one  drop  of  a  two  per  cent, 
solution  of  nitrate  of  silver  into  the  conjunctival  sack  of  each 
eye  of  the  newly  born.  This  destroys  the  virus  whether  it  is 
still  suspended  in  the  fluids  of  the  conjunctival  sack,  or  has 
already  attacked  the  superficial  epithelial  cells  of  the  conjunc- 
tiva. The  more  certain  will  the  result  be  if  to  this  instillation 
be  added  the  careful  washing  and  drying  of  all  the  parts  of  the 
infant  as  they  come  out  of  the  vagina.  Particular  attention  in 
this  should  be  paid  to  the  face  (eyelids)  and  hands,  as  there 
can  hardly  be  any  doubt  but  what  infection  in  some  cases  is 
brought  about  by  particles  of  matter  which  remain  adherent 
to  the  hands  and  face,  and  are  wiped  into  the  eye  a  few  days 
after  birth.  The  importance  of  this  subject  ought  to  be  fully 
recognized  by  every  practitioner,  and  on  his  conscience  and  his 
alone  will  and  must  rest  all  the  blame  for  the  dire  results  if  he 
is  neglectful. 

A  very  great  help  in  the  treatment  of  purulent  conjunctivitis 
and  a  safeguard  against  infection  of  the  conjunctiva  Hes  in  the 
frequent  cleaning  of  the  eye  of  all  discharge  by  means  of  a 
solution  of  bichloride  of  mercury  (i  to  4  or  5,000).  Mild 
cases  may  even  be  successfully  treated  with  this  alone.  Others 
prefer  the  injection  of  liquid  vaseline  under  the  lids. 


DISEASES  OF  THE  CONJUNCTIVA,  101 

With  regard  to  the  treatment  of  the  affection  under  consid- 
eration, the  rule  usually  laid  down  is,  to  make  continued  ice 
applications  alone,  as  long  as  the  discharge  is  scant  and  serous 
and  blood-stained.  When  the  discharge  becomes  purulent 
and  abundant,  caustic  treatment  is  to  be  commenced.  The 
latter  consists  in  the  daily  application  of  a  one  per  cent,  solu- 
tion of  nitrate  of  silver  to  the  whole  conjunctiva.  Corneal  af- 
fections are  no  contra-indication  to  this  treatment,  but  they 
call  for  increased  carefuUness  in  confining  the  application  of 
the  caustic  solution  to  the  conj  unctiva  and  also  for  the  instilla- 
tion of  either  sulphate  of  atropia  or  sulphate  of  eserine  (one 
per  cent). 

To  this  caustic  treatment  may  be  added  other  anti-phlogistic 
measures  besides  the  ice  applications.  These  are  the  applica- 
tion of  leeches  to  the  temple,  or,  what  is  of  greater  value,  scar- 
ification of  the  conjunctiva.  In  some  cases  the  pressure  from 
the  swollen  lids  is  very  great,  and  relief  may  be  given  by  can- 
thotomy. 

Some  surgeons  have  of  late  divided  the  upper  eyelid  into 
two  halves  by  a  vertical  section  through  its  whole  thickness,  in 
order  to  reduce  the  pressure  on  the  eyeball,  and  to  be  able  the 
better  to  remove  the  discharge. 

In  chronic  blennorrhaea  there  is  but  little|swelling  of  the  lids. 
The  conjunctiva,  especially  of  the  fornix  is,  however,  often 
hyperaemic  and  infiltrated,  and  has  a  granular  or  velvety  ap- 
pearance. The  discharge  is  thin  fluid  pus  mixed  with  tear- 
fluid. 

For  the  treatment  of  chronic  blennorrhoea  the  daily  applica- 
tion of  the  sulphate  of  copper  in  substance,  is  often  preferable 
to  the  nitrate  of  silver  solution. 


§55.  Croupous  or  membranous  conjunctivitis  is  as  well  marked 
and  distinct  a  form  of  inflammation  as  is  the  similar  aflection 
of  the  mucous  membrane  of  the  larynx.  Its  characteristic 
feature  is  the  formation  of  a  grayish  white  membrane  on  the 
surface  of  the  conjunctiva,  combined  with  slight  swelling  of 
the  eyelids  and  a  scant  mucus  or  muco-purulent  discharge. 
This  croupous  membrane  may  involve  a  part  only,  or  it  may 


102  OPHTHALMOLOGY. 

cover  the  whole  area  of  the  palpebral  conjunctiva.  It  is,  how- 
ever, never  observed  to  form  on  the  ocular  conjunctiva.  Small 
patches  of  such  a  membrane  are  often  seen  accompanying 
purulent  conjunctivitis. 

At  first  the  croupous  membrane  adheres  rather  firmly  to  the 
conjunctiva,  and  can  be  removed  with  difficulty.  When  the 
affection  has  lasted  a  few  days,  however,  it  may  be  easily  re- 
moved by  rolHng  it  up  with  a  sponge  or  linen  rag,  but  only  to 
be  rapidly  reformed.  The  conjunctiva  beneath  it  is  very  suc- 
culent, its  papillae  are  enlarged,  and  it  has  a  bluish-red  tint. 
The  removal  of  the  croupous  membrane  often  causes  a  slight 
bleeding.  As  the  affection  progresses  the  papillary  swelling 
increases. 

The  cornea  during  a  croupous  conjunctivitis  is  but  rarely 
affected,  although  it  may  be  partially  or  totally  destroyed  by 
ulceration.  Still  the  cases,  in  which  the  croupous  conjunctivi- 
tis leads  to  serious  results  are  very  rare. 

When  tile  croupous  patches  are  small,  continued  ice-water 
appHcations  and  the  instillation  of  a  solution  of  bichloride  of 
mercury  (i  to  5000)  are  in  place.  Daily  caustic  treatment  is 
indicated  when  the  membrane  can  be  easily  detached.  When 
the  membrane  covers  the  whole  inner  surface  of  one  or  both 
eyelids,  and  can  only  with  difficulty  be  removed,  it  is  best  to 
confine  the  treatment  to  cold  applications  and  careful  cleans- 
ing. Only,  when  the  membrane  becomes  loose  and  can  easily 
be  removed,  is  caustic  treatment  advisable. 

The  conjunctiva  is,  furthermore,  sometimes  the  seat  of  a 
diphtheritic  inflammation.  This  affection  is  less  frequent  in 
America,  than  it  is,  for  instance,  in  Germany,  yet  it  is  met 
with  from  time  to  time,  and  in  hospital  practice  it  sometimes 
occurs  epidemically.  Its  cause  is  probably  Loeffler's  bacillus 
of  diphtheria. 

The  appearance  of  conjunctival  diphtheritis  is  so  character- 
istic that  the  physician  who  has  once  seen  a  case,  can  hardly 
confound  it  with  anything  else. 

In  this  form  of  conjunctivitis  the  eyelids  are  swollen,  often 
stiff  and  very  hard,  so  that  they  cannot  be  everted,  or  only 
with  the  greatest  difficulty.  The  pain  is  extreme,  and  is  ag- 
gravated by  the   slightest  pressure.      While  the   exudation  in 


DISEASES  OF  THE  CONJUNCTIVA.  103 

croupous  conjunctivitis  lies  on  the  surface  of  the  conjunctiva, 
in  diphtheritic  conjunctivitis  it  also  fills  the  whole  thickness  of 
the  tissue  of  the  conjunctiva.  The  latter,  therefore,  is  whitish 
in  color  and  anaemic  from  the  pressure  of  the  exudation  around 
the  bloodvessels.  The  diphtheritic  exudation  often  appears 
in  isolated  patches  only.  These  patches  appear  depressed 
when  compared  with  the  surrounding  swollen  and  congested 
conjunctiva.  The  diphtheritic  membrane  cannot  be  removed. 
The  ocular  conjunctiva  is  greatly  swoolen  and  in  rare  cases  it, 
too,  becomes  the  seat  of  diphtheritic  infiltration.  There  is  a 
small  quantity  of  watery  secretion.  An  attack  of  diphtheritic 
conjunctivitis  is  usually  attended  with  fever. 

During  this  affection  the  cornea  very  rarely  remains  intact, 
and  oftener  is  totally  destroyed.  The  eyelids  also  may  suffer 
extensively,  or  may  even  slough  off  altogether. 

After  the  active  stage  of  the  disease  is  past,  which  happens 
in  from  eight  to  ten  days,  the  exudation  is  slowly  dissolved, 
leaving  an  ulcerated  conjunctiva  in  a  state  of  purulent  inflam- 
mation. This  ulceration  may  heal  without  causing  any  de- 
formity, or  it  may  leave  a  considerable  amount  of  scar-tissue 
behind.  Sometimes  necrosis  of  a  portion  of  a  lid  or  the  whole 
lid  is  observed. 

Diphtheritic  conjunctivitis  is  mostly  found  to  be  from  the 
start,  and  to  remain  during  its  course  a  localized  affection ;  a 
fact  which  has  an  important  bearing  upon  the  question  of  diph- 
theria in  general.  It  sometimes  extends  from  a  diphtheritic 
process  in  the  throat  and  nose,  or  begins  in  the  eye  and  travels 
downwards,  but  these  complications  are  rather  rare. 

The  treatment  consists  in  continued  ice  applications  and 
frequent  instillations  of  an  antiseptic  solution.  When  the  ex- 
udation begins  to  dissolve,  the  application  of  caustic  treatment, 
as  in  purulent  conjunctivitis,  is  indicated.  Any  corneal  affec- 
tion must,  of  course,  be  cared  for. 

§56.  Trachoma,  granular  conjunctivitis,  granulated  eyelids,  is 
that  form  of  inflammation  of  the  conjunctiva  in  which  in  addi- 
tion to  swelling  of  the  eyelids,  oedema  and  swelling  of  the  pa- 
pillae of  the  conjunctiva  {^papillary  trachoma)  (See  Fig.  37), 
and  an  abnormal  secretion,  there  is  also  a  formation  of  gran- 


104 


OPHTHALMOLOG  V. 


tiles.  These  latter  are  round,  grayish,  translucent,  sago-like 
bodies,  slightly  elevated  above  the  surrounding  conjunctival 
surface,    but   embedded    in    the    conjunctival    tissue.      They 


Fig.  37. — (After  Saemisch).    Papillary  Trachoma. 

are  aggregations  of  lymphoid  cell?  {lymphomatd),  and  re- 
semble the  lymph-follicles  of  the  intestinal  tract.  (See  Fig. 
38).  Their  usual  seat  in  the  beginning  of  the  affection  is 
the  fornix   of  the    conjunctiva,    but   they   may    spread    over 


Fig.  38. — Trachoma  granule  (lymphoma). 


the  whole  inner  surface  of  the  eyelids,  and  even  to  the 
ocular  conjunctiva  and  corneo-scleral  margin.  Later'  on 
these  granules  undergo  characteristic  changes,  and  give 
rise  to  characteristic  affections  of  the  cornea,  of  the  subcon- 
junctival tissue,  and  of  the  eyelids.  The  presence  of  the  gran- 
ules is  the  characteristic  feature  of  trachoma,  although  they 
may  be  partially  hidden,  in  the  beginning,  by  the  swollen  pa- 
pillae, and  thus  may  for  a  time  escape  detection.  On  the 
other  hand  the  characteristic  results  produced  by  this  form  of 


DISEASES  OF  THE  CONJUNCTIVA.  ]05 

conjunctivitis  in  the  conjunctiva,  cornea  and  eyelids,  enable 
us  to  make  the  correct  diagnosis  of  trachoma  having  existed, 
even  when  the  granules  have  entirely  disappeared. 

The  granules  are  not  arranged  in  any  regular  way,  but  are 
usually  irregularly  grouped.  They  vary  in  size.  After  having  ex- 
isted for  a  certain  time  the  granules  become  organized,  and  are 
transformed  into  connective  tissue,  so  that  in  the  end  their 
former  seat  is  marked  by  scars  in  the  conjunctival  tissue.' 

During  the  progress  of  the  disease  the  papillae  of  the  con- 
junctiva are  also  swollen,  and  the  subconjunctival  tissue  is 
often  greatly  infiltrated;  later  on  this  infiltration  becomes  or- 
ganized, and  the  newly  formed  connective  tissue  contracts, 
causing  shrinkage  of  the  conjunctival  sack  and  atrophy  of  the 
mucous  glands.  The  tarsal  tissue  undergoes  fatty  degenera- 
tion, and  by  the  contraction  of  the  new-formed  scar-tissue  its 
curvature  becomes  gradually  changed.  Thus  the  margins  of 
the  eyelids  are  more  and  more  turned  inward,  and  the  eye- 
lashes begin  to  scratch  the  cornea  (entropium). 

By  the  trachoma  of  the  conjunctiva  itself,  and  by  the  ensuing 
entropium  and  trichiasis,  a  constant  irritation  of  the  cornea  is 
kept  up  and  an  inflammatory  reaction  takes  place  in  its  tissue. 
This  latter  may  progress  but  slowly  and  may  lead  only  to  the 
destruction  of  the  superficial  layers,  or  it  may  progress  rapid- 
ly, and  lead  to  destructive  ulceration  or  even  to  sloughing  of 
the  cornea. 

In  the  former  case  the  superficial  layers  of  the  cornea  at  its 
upper  part  become  dim  and  infiltrated,  the  epithelial  coat  loses 
its  luster,  small  superficial  ulcerations  may  appear,  and  gradual- 
ly bloodvessels  are  seen  to  grow  into  the  infiltrated  tissue  from 
the  corneo- scleral  margin  between  the  corneal  epithelium  and 
Bowman's  layer.  This  condition  is  called  pannuSy  and  may 
extend  downwards  over  the  area  of  the  pupil,  and  thus  render 
the  patient  virtually  blind.     (See  Fig.  39). 

In  the  second  case  we  have  to  deal  with  small  phlyctaenula- 
like  ulcers  springing  up  near  the  corneal  periphery,  or  with  larg- 
er ulcers,  and  abscesses  in  the  corneal  tissue.  These  latter  may 
lead  to  perforation  of  the  cornea  with  prolapse  of  the  iris, 
and  subsequently  to  shrinkage  of  the  globe  or  to  the  formation 
of  a  staphyloma. 


1 06  OPHTHALMOL  OGY. 

Iritis  is  often  observed  in  connection  with  corneal  affections 
dependent  on  trachoma,  and  must  be  considered  as  a  serious 
complication. 


Fig.  39. — Section  through  pannus  of  the  cornea,  showing  that  the  infiltration  lies 
mainly  between  Bowman's  layer  and  the  epithelium. 

Finally  the  shrinking  of  the  conjunctival  sack  may  attain 
such  a  degree,  as  to  render  it  nearly  impossible  for  the  patient 
to  open  his  eyes.  At  this  stage  the  several  ducts  of  the 
lachrymal  glands  are  often  obliterated  and  the  mucous  glands 
of  the  conjunctiva  are  atrophied.  In  consequence  the  con- 
junctiva and  cornea  are  almost  perfectly  dry.  This  condition 
is  called  xerophthalmus. 

The  symptoms  here  described  are  in  the  main  those  of  the 
chronic  form  of  trachoma,  which  is  the  most  frequent  one. 

In  rarer  cases  we  may  have  occasion  to  observe  an  acute 
trachoma,  either  as  a  primary  affection  or  as  an  exacerbation 
during  the  progress  of  chronic  trachoma. 

Acute  trachoma  causes  great  irritation  of  the  eye,  lachry- 
mation  and  swelling  of  the  eyelids  and  conjunctiva. 

There  may  be  a  considerable  amount  of  discharge,  so  that 
the  affection  appears  to  be  an  acute  catarrhal  conjunctivitis. 
As  the  swelling  and  discharge  become  less,  the  conjunctiva, 
especially  that  of  the  lower  lid,  is  found  studded  with  granules. 
Such  attacks  of  acute  trachoma  may  come  on  in  eyes  which 
have  previously  been  in  apparent  health.  If  they  come  on 
during  the  progress  of  a  chronic  trachoma,  the  symptoms  are 
more  or  less  modified  by   the    pre-existing   condition.     Such 


DISEASES  OF  THE  CONJUNCTIVA.  107 

intercurrent  acute  attacks  are,  moreover,  very  apt  to  affect  the 
cornea.  Acute  trachoma  may  end  in  recovery  or  it  may  go 
over  into  the  chronic  form. 

In  the  acute,  as  well  as  in  the  chronic  type  of  trachoma,  the 
subjective  symptoms  are  chiefly  the  feeling  as  of  dust  or  sand 
in  the  conjunctival  sack,  of  heat  in  the  eyelids  and  inability  to 
use  the  eyes  for  any  length  of  time  for  near-work  with  comfort. 
These  symptoms  are  particularly  noticeable  in  the  morning 
and  evening.  The  discharge  sometimes  glues  the  eyelashes 
together,  but  not  always. 

Trachoma  is  rarely  seen  to  affect  one  eye  only.  It  usually 
affects  both  eyes  from  the  beginning,  or  one  is  soon  infected 
from  the  other.  In  chronic  trachoma  the  subjective  symp- 
toms may  for  a  long  time  be  very  mild,  so  that  the  patient  is 
not  even  aware  of  his  disease,  until,  perhaps,  the  eyes  begin 
to  tire  when  used  at  night,  or  to  feel  uncomfortable  in  the 
morning,  or  until  an  intercurrent  acute  attack  brings  him  to 
the  physician. 

Trachoma  is  pre  eminently  a  chronic  disease.  If  left  alone 
it  may  heal  after  many  months  or  years.  When  it  is  healed, 
the  conjunctiva  and  lids,  and  often  the  cornea,  are  not  in  their 
normal  condition,  but  show  changes  characteristic  of  the  di- 
sease. If  no  other  symptoms  are  left  characteristic  bands 
of  scar-tissue  can  usually  be  found  in  the  conjunctiva  of  the 
upper  lid. 

Even  under  the  most  careful  treatment  it  may  take  months 
and  even  years  to  cure  trachoma  although  the  most  modern 
methods  of  treatment  have  rendered  the  disease  much  more 
tractable  and  cut  short  its  duration  to  a  very  gratifying  de- 
gree. Relapses  still  occur,  though  much  less  frequently,  than 
formerly. 

This  most  gratifying  result  has  been  brought  about  by 
modern  antiseptic  agents,  and  since  the  disease  is  directly 
attacked  by  surgical  means. 

Whenever  we  have  to  deal  with  granular  formations  in  the 
conjunctiva,  whether  acute  or  chronic,  or  where  we  can  suspect 
their  presence  within  a  swollen  and  hyperaemic  conjunctiva, 
the  first  step  in  the  treatment  must  be  to  render  the  conjunc- 
tival sack   aseptic  by  means  of  repeated   flushing  with  a  solu- 


108  OPHTHALMOLOGY. 

tion  of  bichloride  of  mercury  (i  to  3,  4  or  5,000),  followed  by 
the  squeezing  out  and  crushing  of  all  granular  (lymphomatous) 
formations.  Since  this  treatment  was  first  advocated  by  Hotz, 
(in  his  method  he  used  the  finger-nails)  it  has  been  greatly 
improved  upon.  A  number  of  instruments  have  been  devised 
among  which  that  of  Knapp  deserves  the  preference,  since  by 
means  of  it  it  is  possible  to  do  this  operation  in  a  most  thorough 
manner.  However,  it  does  not  matter  what  instrument  is  be- 
ing used,  as  long  as  the  granules  are  all  squeezed  out  or  are 
crushed.  This  little  operation  is  quite  painful  and  it  may  be 
necessary  to  give  a  general  anaesthetic  in  order  to  fully  ac- 
complish the  purpose,  whilst  in  most  cases  local  anaesthesia 
by  means  of  cocaine  will  help  the  patient  to  bear  it.  Where 
there  is  little  general  swelling  and  the  granules  are  well  pushed 
to  the  surface,  this  operation  followed  by  the  flushing  with  a 
solution  of  bichloride  of  mercury  several  times  daily,  but 
particularly  night  and  morning,  may  suffice  for  a  cure.  I  have 
seen  eyes  which  after  years  of  treatment  had  been  considered 
fit  only  for  enucleation,  get  well  rapidly  and  become  again  very 
useful,  indeed,  after  this  operation.  Ulcers  and  pannus  disap- 
pear almost  as  if  by  magic.  I  cannot  understand,  how  anyone 
can  go  back  to  the  old  methods  or  depend  on  them  solely  with 
such  a  simple  and  powerful  remedy  at  hand.  It  is  usually  best  to 
follow  up  this  operation  by  a  few  weeks  of  treatment  with  the 
light  application  of  sulphate  of  copper  in  substance. or  nitrate 
of  silver  in  solution.  When  the  corneal  symptoms  predo- 
minate the  employment  of  massage  with  an  ointment  of  yellow 
oxide  of  mercury,  or  aristol  is  in  place.  The  rapidity  of  the 
improvement  is  apt  to  induce  the  patient  to  leave  off  treat- 
ment before  a  cure  is  established.  It  is  best,  however,  to  insist 
on  it  until  the  conjunctival  swelling  is  perfectly  removed.  The 
patient  should  then  keep  on  using  the  flushing  with  the 
bichloride  of  mercury  solution  for  a  month  or  so.  Although  re- 
lapses .under  this  management  have  become  rare,  they  do 
occur  and  I  keep  the  patient,  when  it  is  possible,  under  surveil- 
lance for  a  prolonged  period.  As  a  source  of  relapses  I  have 
often  recognized  granules  hidden  in  the  tissue  of  the  lachrymal 
caruncle  and  semilunar  fold.  Its  best,  therefore,  when  squeez- 
ing the  granules  out  of  the  lids,  not  to  forget  the  caruncle. 


DISEASES  OF  THE  CONJUNCTIVA.  109 

Other  methods  of  treatment  aiming  at  the  removal  of  the 
granules  have  been  highly  recommended,  but  none  of  them 
is  as  simple  and  easy  as  the  one  described,  although  I  do  not 
doubt  they  are  just  as  efficacious. 

The  excision  of  the  conjunctival  folds,  or  the  destruction  of 
the  fornix  by  galvano-cautery  are  unnecessary  and  must  be  con- 
demned since  better  means  have  been  found. 

If  the  palpebral  fissure  has  become  contracted  so  as  to  m- 
terfere  with  the  raising  of  the  upper  eyelid,  canthotomy  or 
canthoplasty  must  be  performed. 

It  seems  to  be  a  pretty  well  established  fact  that  trachoma  is 
due  to  the  infection  with  a  micro-organism  which  differs  but 
little  from  Neisser's  diplococcus  of  gonorrhoea,  and  thus,  per- 
haps, the  origin  of  the  disease  is  to  be  traced  back  to  vaginal 
secretions.  Like  other  micro-organisms,  those  causing  trach- 
oma, thrive  better  in  low,  flat  lands,  than  in  higher  altitudes, 
where  the  disease  is  consequently  not  so  frequent.  The  con- 
tagiousness of  trachoma  is  very  great,  and  endemics  are  not 
rare.  Children  should,  therefore,  be  isolated  and  kept  from 
school  when  affected  by  this  disease. 

Trachoma  is  one  of  the  most  frequent  of  eye-diseases,  and, 
although  oftener  observed  among  the  poor,  it  is  found  in  all 
classes  of  society. 

Where  malaria  is  prevalent,  trachoma  seems  to  be  frequent 
also,  and  I  have  even  heard  it  stated  that  trachoma  is  so  in- 
timately related  to  malaria  that  it  will  yield  to  a nti- malarial 
treatment  to  the  exclusion  of  local  applications.  It  is 
almost  needless  to  say  that  the  latter  idea  is  an  errone- 
ous one,  although  the  conditions  which  favor  malarial  dis- 
eases are  very  much  the  same  as  those  which 
favor  the  appearance  of  trachoma.  Although  anti-ma- 
larial treatment  has  no  direct  value  in  the  treatment  of 
trachoma,  still  the  general  debility,  caused  by  malarial  fever, 
may,  like  any  other  constitutional  affection,  render  the  system 
less  able  to  resist  disease,  and  for  this  reason  only,  an  anti- 
malarial treatment  may  have  a  place  in  the  treatment  of  trach- 
oma. 

When  chronic  trachoma  had  run  its  course  and  little  or  no 
granular  tissue  was  to  be  found  in  the  swollen  conjunctiva,  but 


1 10  OPHTHALMOLOG  V. 

the  eye  remained  very  irritable  and  pannus  persisted,  rendering 
vision  poor  or  useless,  it  was  with  older  surgeons  the  practice 
to  infect  such  eyes  with  purulent  discharge  (gonorrhoeal  pus). 
The  results  in  some  cases  were  evidently  gratifying  enough 
to  allow  of  such  a  practice  to  be  recommended.  However, 
good  these  results  may  have  been,  nobody  is  likely,  I  think, 
to  make  use  of  such  a  remedy  to-day.  It  can  be  the  better  dis- 
pensed with,  since  we  have  a  remedy  by  which  a  similar  inflam- 
mation may  be  produced  in  such  eyes  and  which  is  free  from 
the  most  objectionable  features  of  inoculation  with  pus.  The 
seeds  of  Abrus  precatorius  [Jequirity),  a  leguminous  tropical 
plant,  have  been  used  for  a  long  time  in  Brazil  in  the  treat- 
ment of  trachoma.  This  remedy  was  introduced  into  modern 
therapeutics  by  de  Wecker.  It  may  be  used  in  the  form  of  an  in- 
fusion of  the  shelled  and  crushed  seeds  which  is  brushed  on  the 
conjunctiva  two  or  three  times  until  the  inflammatory  reaction 
begins.  Another  method,  which  I  have  practiced  for 
years  and  can  highly  recommend,  makes  use  of  it  in  the  shape 
of  a  nearly  impalpable  powder,  which  is  applied  directly  to 
the  portions  of  the  conjunctiva  where  the  intensest  reaction  is 
desired.  The  application  in  either  form  causes  a  croupous  con- 
junctivitis which  after  a  few  days  takes  on  a  more  purulent 
character,  and  then  gradually  decreasing,  disappears  in  from 
one  to  two  weeks.  Its  final  effect  is  a  disappearance  of 
the  sweUing  and  roughness  of  the  conjunctiva  and  the  clear- 
ing up  of  the  pannus  to  a  very  considerable  degree.  I  have 
seen  corneae,  which  had  been  useless  for  years  on  account  of 
dense  pannus,  clear  up  to  such  a  degree,  that  they  offered  no 
appearance  of  a  dimness  to  the  naked  eye,  and  the  eyes  could 
be  used  for  the  finest  work  without  discomfort.  Such  a  result 
seldom  follows  one  application  alone;  but  there  is  nothing  to 
hinder  from  making  one  or  more  successive  applications.  The 
effect  of  the  remedy  must  be  carefully  watched,  however,  dur- 
ing the  acute  stage  of  inflammatory  reaction,  as  it  is  known  to 
have  caused  the  formation  of  deleterious  ulceration  of  the 
cornea.  The  more  vascular  the  pannus  is,  the  less  such  a  re- 
sult is  to  be  dreaded.  I  might  almost  say,  the  worse  the  con- 
dition of  the  cornea  before  the  application,  the  better  the 
prognosis    for   the  results  of  a  jequirity   inflammation.      After 


DISEASES  OF  THE  CONJUNCTIVA.  Ill 

the  effects  of  this  inflammation  had  perfectly  passed  away,  I 
have  frequently  found  formerly  unsuspected  nests  of  granules 
remaining  behind,  and  have  squeezed  them  out. 

There  are  several  milder  forms  of  granular  conjunctivitis 
which  are  by  some  considered  diseases  of  a  totally  different 
nature  on  account  of  the  different  clinical  picture  they  repre- 
sent. Histologically  they  cannot  be  distinguished  from  the 
trachoma  we  have  described.  It  is,  however,  well  to  know 
that  the  small  follicle-like  granules  which  may  be  found  in  the 
lower  or  upper  fornix,  and  are  accompanied  by  annoying  but 
not  violent  symptoms  [follicular  catarrh,  follicular  trachoma) 
are  not  apt  to  develop  into  the  more  serious  form,  although  this 
does  happen.  It  is  best  for  practical  purposes  to  rid  the  pa- 
tient of  whatever  granules  are  found  in  the  conjunctiva  in  the 
manner  above  detailed. 

The  treatment  of  the  corneal  affections  dependent  on  trach- 
oma will  be  spoken  of  in  Chapter  VIII. 

The  operative  treatment  of  the  affections  of  the  eyeHds 
caused  by  the  same  disease  has  already  been  detailed  in 
Chapter  III. 

§57.  Another  form  of  inflammation  to  which  the  conjunctiva 
is  subject,  especially  in  childhood,  is  the  phlyctcsnular  (so-called 
strumous  or  lymphatic)    conjunctivitis.     It  affects  primarily  the 


Fig.  40. — (After  Dalrymple).     Phlyctaenulse  of  the  conjunctiva. 

ocular  conjunctiva,  and  especially  the  limbus  conjunctivae.  (See 
Fig.  40).  On  the  injected  and  infiltrated  conjunctiva  a 
small  papula  or  vesicle  is  formed,  or  sometimes  several  at  the 
same  time.     This   vesicle  contains  in  most  cases  only  a  serous 


112  OPHTHALMOL  OGY. 

fluid  and  a  few  round  cells,  which  are  arranged  around  a  ter- 
minal nerve  twig.  The  inflammation  may  remain  confined  to 
the  neighborhood  of  the  vesicle  or  it  may  spread  over  the  en- 
tire ocular  conjunctiva  of  the  eyelids.  Frequently  we  find  the 
same  formation  of  vesicles  also  on  the  cornea  {phlyctcenular 
keratitis).  By  and  by  the  vesicle  bursts,  its  contents  escape, 
and  a  small  ulcer  remains  in  its  place.  The  ulcer  may  now 
gradually  heal,  or  the  morbid  process  may  be  continued  by 
the  successive  appearance  of  new  vesicles.  In  some  cases 
this  vesicle  is  secondarily  infected  by  some  pyogenous  micro- 
organisms and  a  pustule  or  small  abscess  results  {pustular  con- 
junctivitis). In  other  cases  a  pannus-like  infiltration  takes 
place  {pannus  scrophulosus). 

In  some  cases  the  general  irritation  is  but  slight;  in  many 
cases,  however,  it  is  very  great.  The  eyelids  are  oedematous 
and  hot;  there  is  continued  lachrymation,  and  such  a  dread  of 
light  that  a  child  suffering  from  this  affection  will  not  only 
hide  the  face  in  the  day  time,  whenever  this  is  possible,  but 
even  bury  it  deeply  in  the  pillow  at  night. 

All  these  symptoms  lead  to  the  production  of  blepharitis. 
The  skin  becomes  irritated  and  excoriated,  and  in  warm 
weather,  especially,  the  whole  face  may  present  a  continuous 
surface  in  a  state  of  eczematous  inflammation.  There  is  fre- 
quently tonic  blepharospasmus  combined  with  the  photo- 
phobia. 

The  disease  belongs  essentially  to  childhood,  and  is  but 
seldom  found  in  the  adult. 

It  is  probably  due  to  an  infection  from  the  mucous  dis- 
charge of  the  nose,  which  is  never  wanting  in  such  cases. 
I  have  made  it  a  rule,  therefore,  for  years  to  advise  the 
parents  to  that  effect  and  to  have  them  pin  a  clean  handker- 
chief daily  to  the  child's  dress,  which  is  to  be  used  to  wipe 
the  eyes  only.  The  disease  is  more  frequent  among  unclean- 
ly, than  among  the  well-kept  and  well-washed  children. 

The  severer  cases,  and  especially  such  as  show  a  tendency 
to  frequent  relapses,  are  generally  accompanied  by  marked 
signs  of  scrophulosis.  Phlyctaenular  conjunctivitis  is  not  as 
contagious  an  affection  as  the  other  forms  of  conjunctivitis. 
It  leads  but  seldom  to  serious  consequences,  and  may  even  get 


DISEASES  OF  THE  CONJUNCTIVA.  113 

well  without  medical  interference.  Yet,  as  the  primary  cause 
is  not  easily  removed,  relapses   are  frequent,  or  even  the  rule. 

Besides  the  general  treatment,  which  is  directed  against  the 
constitutional  disorder,  (iron,  iodides,  cod-liver  oil,  salt  water 
baths,  etc.,)  this  affection  calls  for  vigorous  local  treatment. 
This  consists  in  cold  applications  and  in  the  daily  insperga- 
tion  of  calomel  or  iodoform,  or  the  use  of  the  ointment  con- 
taining from  I  to  4  per  cent,  of  yellow  oxide  of  mercury. 

To  this  I  always  add  the  frequent  flushing  of  the  conjunctival 
sack  with  a  four  per  cent,  solution  of  boracic  acid.  Milder 
cases  will  get  well  with  such  a  solution  alone.  The  photo- 
phobia and  blepharospasmus  may  be  relieved  by  the  instilla- 
tion of  a  cocaine  solution.  This  will  in  most  cases  replace  the 
older  methods  of  forcibly  opening  the  eyes  or  dipping  the  face 
into  a  basin  with  cold  water.  In  fact  in  the  treatment  of 
phlyctaenular  conjunctivitis  concaine  plays  a  very  important 
role.  Not  only  can  all  treatments  better  and  more  thoroughly 
be  applied,  but  the  children,  being  enabled  to  keep  the  eyes 
open,  are  more  willing  to  play  out-doors  and  are  more  prone 
to  stand  some  light,  two  great  factors  in  effecting  a  quicker 
cure.  Atropine  need  now  hardly  be  used,  excepting  when 
deeper  seated  corneal  affections  accompany  the  phlyctaenular 
conjunctivitis. 

§58.  During  an  attack  of  measles,  or  preceding  it,  the  con- 
junctiva may  become  the  seat  of  an  inflammation  (exanthema- 
tic  conjunctivitis).  It  has  usually  the  character  of  an  acute 
catarrhal  conjunctivitis  and  may  be  accompanied  by  consider- 
able discharge.  It  needs  no  special  treatment,  although  it 
may  be  well  to  flush  the  conjunctival  sack  with  a  solution  of 
boracic  acid. 

Pemphigus  sometimes  is  observed  to  occur  in  the  conjunc- 
tiva. It  may  affect  the  conjunctiva  alone  or  exist  at  the 
same  time  in  other  parts  of  the  body.  Small  spots  are  found 
in  the  conjunctiva  which  instead  of  the  epithelium  are  covered 
with  a  grayish  exudation.  As  these  spots  are  gradually 
changed  into  cicatricial  tissue,  others  appear,  and  in  this  man- 
ner the  whole  of  the  conjunctival  sack  may  be  destroyed  and 
the  eyelids  become  glued  to  the  eyeball.     The  cornea  thus  be 


114  OPHTHALMOLOGY. 

ing  continually  covered,  the  eyes  become    useless.     It  usually 
attacks  both  eyes.     No  treatment  seems  to  be  of  any  avail. 

§59.  Among  the  wounds  and  injuries  of  the  conjunctiva 
none  are  of  great  importance,  or  require  special  treatment  ex- 
cept burns. 

Burns  with  gun  powder,  if  they  concern  the  conjunctiva 
only,  are  usually  of  little  importance.  Yet  if  a  great  many 
grains  of  powder  are  embedded  in  the  conjunctiva,  it  is  best 
to  remove  them  by  cutting  them  out,  by  lifting  up  a  minute 
fold  of  conjunctiva  with  fine  forceps  and  snipping  it  off  with 
scissors,  or  by  touching  them  with  galvano-cautery. 

Burns  with  hot  water,  steam  or  carbolic  acid,  though  pain- 
ful at  first,  are  but  rarely  of  much  significance  Cocaine  in- 
stillations to  allay  the  pam  and  cool  compresses  are  usual  all, 
that  is  required,  and  regeneration  takes  place  in  a  few  days. 

Burns  by  acids  or  alkalies,  especially  by  lime  or  by  melted 
metals  and  glass,  may  give  rise  to  the  most  disagreeable  affec- 
tions, through  the  destruction  of  the  tissues.  Lime  in- 
filtrates the  tissues  to  a  considerable  depth,  and  thus  sticks 
fast  to  them.  If  an  eye  burnt  with  lime  is  seen  immediately, 
a  careful  washing  out  of  the  conjunctival  sack  with  acidulated 
water  (vinegar  will  do)  may  in  some  measure  limit  the  destruc- 
tive action,  but  unfortunately  we  seldom  see  such  cases  early 
enough  to  do  much  in  this  way. 

In  all  cases  of  burns  of  the  conjunctiva  the  first  thing  to  be 
done  is  to  cleanse  the  conjunctival  sack  carefully  of  all  foreign 
substances  which  can  be  easily  removed.  This  done,  atropine 
and  cocaine  should  at  once  be  instilled  and  ice  applications  be 
made. 

If  the  destruction  extends  to  the  subepithelial  tissue  of  the 
ocular  and  palpebral  conjunctiva,  and  perhaps  to  the  cornea, 
the  ulcerated  surfaces,  lying  continually  in  close  contact,  may 
grow  together,  thus  forming  a  symblepharon.  (This  may  also, 
happen  from  diphteritic  ulceration).  In  mild  cases  we  my 
sometimes  succeed  in  preventing  its  formation  by  keep- 
ing the  eyehd  everted  as  much  as  possible,  but  as  a  rule 
symblepharon  will  occur  in  spite  of  all  our  efforts.  Instilla- 
tions of  oil  into  the  conjunctival    sack,   are    usually   resorted 


DISEASES  OF  THE  CONJUNCTIVA.  115 

to,  but  are  of  little  value.  I  have  seen  better  results  in  several 
cases  where  the  melted  metal  could  not  at  once  be  removed 
from  the  lower  conjunctival  sack,  and  where  by  its  presence  it 
subsequently  successfully  opposed  the  formation  of  a  symble- 
pharon.  I  am  therefore  inclined  to  think,  that  where  the 
burn  of  the  conjunctiva  is  caused  by  melted  metal,  which  is 
unirritating  in  its  nature,  and  is  usually  flattened  out  smoothly, 
its  presence  in  the  conjunctival  sack  might  be  allowed  for  some 
time  under  careful  watching.  In  the  same  manner  shields  of  cellu- 
loid or  hard  rubber  have  been  recommended  to  be  worn  in  the 
conjunctival  sack  until  healing  has  taken  place.  We  must,  of 
course,  be  on  our  guard  against  possible  injury  to  the  cornea, 
which,  however,  is  not  very  likely  to  result  from  the  presence  of 
a  smooth,  indifferent  foreign  body  lying  in  the  lower  cul-de-sac. 

§60.  In  rare  cases  the  conjunctiva  has  been  found  to  be  the 
seat  of  a  localized  primary  or  secondary  tuberculosis.  The 
tubercles  appear  as  small  trachoma-like  nodules  which  may 
increase  in  size  and  number,  coalesce,  and  finally  become 
superficially  ulcerated.  The  presence  of  tubercle  bacilli  alone 
will  render  the  diagnosis  certain.  Early  destruction  of  the 
nodules  by  galvano-cautery,  or  their  excision  may  bring  about 
a  cure.  Lupus  which  also  attacks  the  conjunctiva  usually 
grows  into  it  from  the  neighboring  skin. 

Syphilitic  ulcers  may  also  be  found  in  the  conjunctiva.  They 
are  mostly  initial  chancers,  produced  by  kissing.  Sometimes 
they  appear  to  be  tertiary  (gummatous)  lesions. 

An  amyloid  degeneration  of  the  conjunctiva  has  been  seen 
by  a  number  of  observers.  It  is  characterized  by  a  yellowish, 
translucent  swelling  of  this  membrane,  especially  of  its  fornix. 
This  swelling  may  grow  until  it  interferes  with  the  movements 
of  the  lids,  when  its  removal  is  indicated.  No  other  treatment 
seems  to  be  of  use.  The  chemical  reaction  will  ensure  the 
diagnosis. 

(Edema  of  the  conjunctiva  when  not  due  to  an  inflammatory 
condition  of  the  lids  or  eyeball  may  be  one  of  the  symptoms 
of  trichinosis.  It  is  present  to  a  slight  degree  in  the  eyes  of 
heavy  drinkers,  and  it  may  occur  in  patients  who  for  some 
other  aflection   are  taking  one  or  the  other  of  the  iodide  salts. 


116  OPHTHALMOLOG  Y. 

Subconjunctival  ecchymosis  is  frequently  observed  as  a  result 
of  contusions;  also  after  a  fit  of  violent  coughing,  as  in  whoop- 
ing cough,  etc.  It  is  harmless,  and  calls  for  no  treatment;  in 
fact,  treatment  is  wholly  unavailing  to  hasten  the  absorption 
of  the  extravasated  blood,  which  will  disappear  of  itself  in 
from  two  to  four  weeks,  according  to  circumstances.  Gentle 
massage  may,  perhaps,  hasten  this  absorption. 

§6i.  When  the  palpebral  and  ocular  conjunctiva  near  the 
corneo-scleral  margin,  or  the  palpebral  conjunctiva  and  the 
cornea  are  grown  together  in  the  shape  of  a  bridge,  the  con- 
dition is  called  symblepharon  anterius.  When  the  union  has 
taken  place  farther  back  in  the  conjunctival  sack  and  reaches 
to  the  very  fornix  of  the  conjunctiva,  it  is  called  a  symblepha- 
ron posterius.  It  is  clear  that  any  such  attachment  between 
eyelid  and  eyeball  must  impede  their  movements.  When 
the  whole,  or  at  least  the  largest  part  of  the  conjunctival 
sack  is  thus  obliterated  by  the  union  of  the  palpebral  with  the 
ocular  conjunctiva,  and,  perhaps,  with  the  cornea,  we  speak  of 
anchyloblepharon.  In  this  condition  the  movements  of  the 
eyeball  and  eyelids  are,  of  course,  almost  totally  abolished; 
the  eye  also  is  generally  so  far  damaged,  as  to  be  worthless 
as  an  organ  of  vision. 

In  symblepharon  anterius,  in  which  the  fornix  is  not  in- 
volved and  in  which  the  adhesion  forms  a  bridge-like  band, 
connecting  the  eyeball  with  the  eye-lid,  the  simple  division  of 
this  bridge  is  generally  sufficient;  but  in  cases  of  more  ex- 
tensive symblepharon  division  of  the  band  is  unavailing,  unless 
some  means  can  be  devised  to  fill  the  gap  resulting  from  the 
destruction  of  the  ocular  or  palpebral  conjunctiva.  This  may 
be  affected  by  covering  the  ocular  wound-surface  by  con- 
junctival flaps  from  the  same  eye,  by  transplantation  of  flaps 
from  other  (even  rabbits)  eyes,  or  by  covering  the  defect  on 
the  inner  surface  of  the  eyelid  by  a  cutaneous  flap  tilted  over 
the  lid-margin  or  even  drawn  through  a  cut  through  the  lid 
{boutonniere)   and  fastened  to  the  inside. 

In  cases  of  symblepharon  of  the  lower  eyelid  it  has  also 
been  recommended  to  keep  the  eyelid  permanently  everted 
after  the  dissection,  until  the  wounds  are  healed  by  means  of  a 
needle  run  through  a  fold  of  skin. 


DISEASES  OF  THE  CONJUNCTIVA.  117 

§62.  The  conjunctiva,  especially  its  ocular  portion,  is  some- 
times the  seat  of  tumors,  which  may  be  either  benign  or 
malignant. 

Lymphangiectasia,  distention  of  lymph-channels,  is  some- 
times seen  in  the  ocular  conjunctiva  as  a  small  transparent  and 
shining  conglomeration  of  bead-like  bodies  which  lie  in  the 
subconjunctival  tissue  and  can  be  moved  about  with  it.  They 
are  seldom  large  enough  to  cause  any  annoyance.  When 
they  do,  they  may  be  made  to  disappear  by  puncture,  or  by 
cutting  off  their  anterior  wall  with  scissors. 

Pinguecula^  a  small  yellowish  elevation  near  the  corneo- 
scleral margin  on  the  medial  or  lateral  side  of  the  cornea  and 
in  the  line  of  the  palpebral  fissure,  is  perfectly  harmless.  Its 
name  would  imply  that  it  is  of  a  fatty  nature,  which,  however, 
is  not  the  case.  It  is  simply  condensed  and  histologically 
changed  subconjunctival  tissue  and  its  formation  is  probably 
due  to  the  movements  of  the  eyelids.  If  it  becomes  inflamed 
and  swollen,  and  thus  gives  rise  to  annoyance,  besides  being  in 
some  measure  disfiguring,  it  may  be  removed  by  a  clip  of  the 
scissors. 


Fig.  41. — Pterygium  internum  of  the  left  eye. 

Pterygium  (wing-skin)  is  a  triangular  fold  of  conjunctival 
tissue,  widest  near  one  angle  of  the  palpebral  fissure  or  the 
fornix,  and  more  or  less  pointed  at  its  insertion  on  the 
corneo-scleral  margin  or  on  the  cornea.  It  is  oftenest  found 
on  the  nasal  side,  more  rarely  on  the  temporal  side  of  the  eye- 
ball, occasionally  in  the  direction  of  one  or  the  other  rectus 
muscle.  It  may  for  a  long  time  remain  stationary;  when  in- 
flamed, however,  it  is  apt  to  grow  farther  towards  the  centre 
of  the  cornea,  and  thus  it  may  in  time  interfere  with  vision 
and  even  destroy  it.  Its  presence  is  frequently  a  cause  of 
chronic  conjunctivitis.    (See  Fig.  41). 


118  OPHTHALMOLOG  K 

The  formation  of  pterygium  may  be  due  to  a  marginal  ulcer 
of  the  cornea,  to  which  an  overlapping  fold  of  the  nearest 
part  of  the  ocular  conjunctiva  has  become  adherent.  We  find, 
therefore,  in  transverse  sections  a  layer  of  conjunctival  epi- 
thelium, incarcerated  between  it  and  the  cornea  or  sclerotic, 
undergoing  retrogressive  metamorphosis.  I  have  seen  two 
cases  in  which  this  colloid  metamorphosis  of  the  incarcerated 
epithelial  cells  had  caused  the  formation  of  a  cyst  under  the 
pterygium,  which  on  being  punctured  discharged  a  small 
quantity  of  viscid,  colloid  matter. 

As  it  is,  however,  often  seen  to  develop  without  any  visible 
ulceration,  there  must  be  other  causes  which  lead  to  it.  A 
mechanical  explanation,  if  I  may  call  it  so,  was  offered  by 
Young,  which  I  think  is  an  excellent  one,  for  the  formation  of 
internal  pterygium  as  seen  so  frequently  in  farmers,  seamen, 
firemen,  engineers  and  railroad  employees,  in  short  among 
men  exposed  to  rough  weather,  dust  and  heat.  When  trying 
to  shut  the  eye  to  keep  off  these  irritants,  the  orbicularis  mus- 
cle is  contracted  tightest  at  the  temporal  side,  while  near  the 
nasal  side  enough  of  it  is  left  comparatively  relaxed  in  order 
to  have  a  small  triangular  opening  to  see  through.  It  is  then, 
of  course,  on  that  part  of  the  conjunctiva  that  all  the  contents 
of  the  air  will  be  deposited,  and  that  is  just  where  pterygium 
occurs  most  frequently. 

Theobald  tries  to  account  for  internal  pterygium  by  the  hy- 
peraemia  produced  by  the  use  of  the  internal  recti  during  near 
work.  Unfortunately,  pterygium  is  but  rarely  found  among 
the  class  of  people  who  use  their  eyes  for  near  work  contin- 
ually, while  it  is  frequent  among  those  classes  that  rarely,  if 
ever,  read. 

Fuchs  takes  the  position  that  every  pterygium  originates  in 
a  Pinguecula,  an  opinion  which  Horner  and  others  held  before 
him.  That  a  pinguecula  may  develop  into  a  pterygium  cannot 
be  doubted,  but  a  pinguecula  alone  does  not  make  a  pterygium. 
There  must  be  other  forces  at  work,  for  whose  applied  energy 
the  Pinguecula  may  form  an  especially  favorable  point  of  at- 
tack.   According  to  Poncefs  theory  these  are  micro-organisms. 

Whatever  the  ultimate  cause  may  be,  the  pterygium  grows 
into  the  corneal  tissue  in  the  shape   of  a   wedge,  which   raises 


DISEASES  OF  THE  CONJUNCTIVA.  119 

the  superficial  layers,  Bowman's  membrane  and  the  epithelium. 
In  this  growth  the  conjunctiva  is  dragged  along  in  such  a  man- 
ner as  to  impede  the  movements  of  the  eye  in  the  opposite  di- 
rection. In  internal  pterygium  the  semilunar  fold  disappears 
and  the  lachrymal  caruncle  may  be  dragged  a  considerable 
distance  from  its  original  situation  and  towards  the  cornea. 

Pterygium  shoul  be  removed  as  soon  as  it  begins  to  encroach 
on  the  cornea  or  causes  continued  irritation. 

A  number  of  methods  have  been  devised  for  accomplishing 
this.  In  spite  of  a  thorough  operation  relapses  or  newly 
formed  pterygia  are  occasionally  met  with. 

In  the  improved  method  of  Knapfs  the  pterygium  is  first 
carefully  dissected  off  the  cornea  and  sclerotic  and  then  by  a 
horizontal  cut  divided  into  an  upper  and  a  lower  half,  one  of 
which  is  to  be  stitched  into  the  lower  and  the  other  into  the 
upper  fornix. 

The  gaps  into  which  these  halves  of  the  pterygium  are  to 
be  stitched  are  formed  by  making  an  incision  through  the  con- 
junctiva from  the  base  of  the  pterygium  upward  and  down- 
ward into  the  fornix. 

Another  method  is  that  of  Gale zow sky.  After  the  ptery- 
gium has  been  thoroughly  dissected  off  the  cornea,  the  tissue 
towards  its  base  is  undermined  with  the  scissors.  Finally  a 
thread  armed  with  two  needles  is  carried  through  the  apex  of 
the  pterygium  so  as  to  form  a  loop,  and  its  ends  are  brought 
out  through  the  conjunctival  tissue  at  the  base  of  the  ptery- 
gium. When  the  threads  are  tied,  the  apex  is  folded  under  so 
that  the  pterygium  is  doubled  on  itself.  This  causes  at  first 
the  appearance  of  a  disfiguring  swelling,  but  as  the  pterygium 
atrophies  this  swelling  disappears. 

Prince  advocates  simple  evulsion  of  the  pterygium  with  the 
forceps.  He  claims  for  this  somewhat  barbaric  method,  that 
the  cornea  is  clearer  when  all  is  healed  than  by  any  other 
method. 

The  oldest  method  is  to  excise  the  tissue  of  the  pterygium 
in  the  shape  of  a  rhomboid,  after  it  has  been  well  dissected 
off  the  cornea  and  sclerotic.  A  partial  closure  of  the  result- 
ing gap  in  the  conjunctiva  by  undermining  this  membrane 
upwards  and  downwards  and  stitching  the   wound-lips  togeth- 


1 20  OPHTHALMOL  OGY 

er,  may  follow  the  excision.  I  have  for  years  performed  this 
operation,  preceded  by  a  thorough  flushing  of  the  conjunctival 
sack  with  a  bi-chloride  of  mercury  solution,  and  followed  by 
a  cauterization  of  the  corneal  wound  with  pure  carbolic  acid. 
The  patient,  when  discharged,  is  further  directed  to  keep  on 
using  the  solution  of  bi-chloride  of  mercury  for  several  weeks 
longer.  Although  I  have  operated  on  a  large  number  of  pa- 
tients for  pterygia  of  all  sizes,  relapses  after  this  method 
have  been  extremely  rare. 

The  conjunctiva  near  the  corneo-scleral  margin  is  sometimes 
the  seat  of  a  congenital  growth  of  dermoid  tissue.  The  little 
tumor  usuall  encroaches  upon  the  cornea.  It  consists  of  all 
the  elements  of  the  skin,  including  hair.  When  annoying  by 
its  appearance  or  on  account  of  irritation  caused  by  the  hair, 
it  should  be,  and  is  easily,  removed. 

Congenital  sub- conjunctival  lipoma  is  sometimes  found  with 
dermoid  or  separately. 

Cystic  formations^  not  of  a  lymphangiectatic  nature,  are 
sometimes  met  with  in  the  conjunctiva  They  may  be  easily 
excised,  when  they  cause  any  annoyance. 

Granulomata^  (^polypus,  proud  fleshy  sometimes  spring  from 
the  conjunctiva  during  inflammatory  conditions  and  after  injur- 
ies or  operations.  They  may  be  pedunculated  or  have  a  broad 
base.  Their  removal  with  the  scissors  is  simple  and  may  or 
may  not  be  followed  by  cauterization  of  the  wound. 

The  malignant  tumors  found  in  the  conjunctiva  are  either 
epitheliomatous  or  sarcomatous  in  character.  When  either  of 
these  originate  in  the  conjunctival  tissue,  they  begin  at  or  near 
the  limbus  of  the  ocular  conjunctiva.  In  its  growth  the  epi- 
thelioma gradually  advances  on  the  cornea  spreading  first  be- 
tween Bowman's  layer  and  the  corneal  epithelium.  Later  on 
Bowman's  layer  is  perforated  and  the  growth  spreads  into  the 
corneal  tissue  proper.  It  may  lead  to  perforation  of  the  cor- 
nea and  thus  find  a  way  into  the  iris  and  into  the  deeper  por- 
tions of  the  eyeball.  It  may  also  reach  the  interior  of  the 
eyeball  along  one  or  more  of  the  larger-blood  vessels  which 
pierce  the  sclerotic. 

The  sarcomata  are  mostly  pigmented.  They  grow  much  in 
the  same  manner  as  that    of  an    epithelioma,  and   sometimes, 


DISEASES  OF  THE  CONJUNCTIVA. 


121 


while  spreading  into   the  corneal   tissue,  the    sarcoma  is   also 
seen  to  grow  around  the  corneo-scleral  margin.    (See  Fig.  42). 


Fig.  42. — Pigmented  episcleral  sarcoma  encroaching  upon  the  cornea.  The  growth 
has  spread  quite  a  distance  towards  the  center  of  the  cornea  under  the 
epithelium  and  without  destroying  Bowman's  layer.  It  is  now  entering 
the  corneal  tissue  proper  at  the  corneo-scleral  margin. 

It  is  possible  in  the  early  stages  to  remove  these  tumors 
successfully,  when  they  have  not  yet  pierced  Bowman's  layer. 
Their  destruction  by  galvano-cautery  may  be  recommended 
when  the  cornea  is  not  yet  deeply  implicated.  Later  on  the 
eye  has  to  be  sacrificed. 


CHAPTER   VIII.— DISEASES    OF   THE   CORNEA. 

§63.  All  forms  of  inflammation  of  the  cornea,  keratitis, 
cause  a  dimness  of  a  part  of,  or  even  of  the  whole  area  of,  the 
cornea.  This  dimness  is  due  to  the  infiltration  of  the  corneal 
tissue  with  cells  which  wander  into  it,  or  are  newly-formed 
within  it.  Such  an  infiltration  may  either  become  absorbed  or 
lead  to  the  formation  of  pus.  It  may  lie  superficially  or  con- 
cern the  deeper  lamellae  alone,  or  it  may  pervade  the  whole 
thickness  of  the  cornea.  The  resulting  dimness  may  disappear 
altogether  later  on  or  remain  permanent. 

Keratitis  is  usually  accompanied  by  asymptomatic  conjunct- 
ivitis which  may  be  but  barely  perceptible  or  be  quite  a  prom- 
inent symptom.  Iritis  may  be,  and  often  is,  seen  as  a  compli- 
cation. During  the  absorption  blood-vessels  are  often  seen 
to  grow  into  the  corneal  tissue.  They  spring  from  the  termi- 
nal loops  in  the  periphery  of  the  cornea  or  from  the  scleral 
blood-vessels  (see  Chapter  I).  Such  newly  formed  blood-ves- 
sels may,  during  the  healing  process  or  even  afterwards,  atro- 
phy and  disappear;  in  a  minority  of  the  cases  they  remain 
persistent.  Keratitis  may  attack  one  eye  only,  some  forms 
of  it  nearly  always  affect  both  eyes,  although  not  always  at 
the  same  time. 

As  a  general  rule,  the  danger  of  a  complicating  iritis  makes 
it  necessary  in  cases  of  keratitis  to  at  once  instill  atro- 
pine and  to  keep  the  pupil  dilated.  In  a  few  exceptional  cases 
eserine,  which  causes  the  pupil  to  contract,  may  for  the  time 
be  indicated,  especially  when  the  intra-ocular  tension  is  in- 
creased and  a  perforation  of  the  cornea  is  to  be  feared.  To 
allay  pain,  which  is  sometimes  very  severe  in  corneal  affec- 
tions, the  bathing  of  the  eye  with  hot  water,  the  use  of  steam 
thrown  against  the  lids  by  an  atomizer,  or  of  the  Japanese  hot 
box,  and  the  instillation  of  a  4  per  cent,  solution  of  cocaine 
are  to  be  relied  upon.    Cocaine,  however,  should  be  used  mod- 

—122— 


DISEASES  OF  THE  CORNEA.  123 

erately.     Its   too  free  use  has  a  bad  effect  on  the  nutrition  of 
the  cornea,  and  consequently  on  the  process  of  repair. 

§64.  Phlyctaenular  keratitis  (keratitis  phlyctaenulosa,  lymph- 
atica,  strumosa)y  is  essentially  the  same  affection  as  phlyctae- 
nular conjunctivitis,  and  as  has  been  stated  under  that  head, 
the  one  is  very  often  seen  associated  with  the  other.  (See 
Chapter  VIII).  The  treatment  is  exactly  the  same,  and  need 
not  be  again  insisted  on.  The  affection  often  leaves  no  trace 
behind,  only  where  the  phlyctaenular  ulcer  has  involved  Bow- 
man's and  some  deeper  layers,  a  slight  scar  is  formed,  which 
later  on  appears  as  a  small  gray  spot  [macula).  In  other  cases 
in  which  a  leash  of  blood-vessels  extends  from  the  periphery 
towards  the  seat  of  the  phlyctaenula  {fascicular  keratitis),  these 
may  remain  for  some  time  after  the  heeling  of  the  phlyctaenu- 
la. The  blood-vessels  usually  disappear  later  on,  but  often 
leave  a  dimness  of  the  cornea  in  their  place. 

As  in  phlyctaenular  conjunctivitis  the  phlyctaenula  may  be- 
come secondarily  infected  with  pyogenous  germs.  The  result 
is  a  larger  pustule  {keratitis  pustulosa),  which  gives  the  disease 
a  graver  aspect. 

Sometimes  a  number  of  phylctaenulae,  appearing  like  mili- 
ary tubercles,  are  formed  at  the  same  time  or  in  quick  succes- 
sion near  the  corneo-scleral  margin,  but  this  form  of  miliary 
phlyctaenulae  differs  from  the  other  form  in  no  other  way. 

Although  the  treatment  of  phlyctaenular  keratitis  is  the  same 
as  that  of  phlyctaenular  conjunctivitis,  we  have  to  add,  that 
in  the  keratitis  it  is  best,  as  a  rule,  to  instill  atropine.  The 
tonic  treatment  of  the  general  system  should  never  be  forgot- 
ten in  these  casbs  (syrupus  ferri  iodati,  cod-liver  oil,  salt  water 
baths,  etc.)  The  disease  frequently  recurs,  but  the  tendency 
to  its  recurrence  dies  out  near  the  age  of  puberty.  In  rare 
cases  it  is  observed  in  the  adult. 

§65.  There  are  several  other  forms  of  keratitis  character- 
ized by  the  formation  of  small  vesicles  which  must  not  be 
confounded  with  phlyctaenular  keratitis.  In  febrile  diseases 
and  sometimes  during  an  attack  of  herpes  zoster  ophthalmicus, 
small  vesicles  are  seen  to  spring  up  on  the  surface  of  the  cor- 
nea.   The  eye  is  then  in  a  state  of  considerable  irritation  and 


124  OPHTHALMOLOGY. 

sometimes  very  painful.  As  the  vesicles  burst  small  ulcers  re- 
sult and  by  the  confluence  of  such  ulcers  the  ulcerated  sur- 
face may  appear  branched  in  several  directions  [keratitis  den- 
dritic a). 

Keratitis  bullosa  is  another  form  of  inflammation  of  the  cor- 
nea in  which  vesicles  are  formed.  This  disease,  according  to 
Landesberg,  is  primarily  an  inflammation  of  the  deeper  portions 
of  the  cornea  with  the  formation  of  an  exudation  below  Bow- 
man's layer,  or  between  it  and  the  epithelium.  The  affection 
is  accompanied  by  great  irritation  and  pain  and  an  increased 
intraocular  pressure.  These  symptoms  subside  when  the  vesi- 
cle bursts  or  is  opened.  Relapses  and  intercurrent  exacerba- 
tions are  the  rule.     Treatment  seems  to  be  of  little  use. 


Fig.  43. — (After  Nuel.)     Keratitis  filamentosa.  Microscopic  appearance  of  a  thread- 
like epithelial  body,  and  the  region  of  the  cornea  from  which  it  springs. 

Of  late  a  number  of  observers  have  described  a  form  of  su- 
perficial keratitis  in  which  small  thread-like  formations  are 
seen  to  hang  from  the  cornea  {keratitis  filamentosa).  Micro- 
scopical examinations  have  made  it  clear  that  these  threads 
which  were  thought  to  be  fibrine,  are  in  reality  excrescences 
of  the  corneal  epithelium  which  grow  with  a  peculiar  twist. 
{Hess,  Nuel).    (See  Fig.  43). 


DISEASES  OF  THE  CORNEA.  125 

%(i6.  Keratitis  affecting  particularly  the  deeper  seated  por- 
tions of  the  cornea  is  called  parenchymatous  keratitis  (keratitis 
interstitialis,  punctata,  profunda,  syphilitica,  scrofulosa).  This 
affection  may  be  ushered  in  by  a  state  of  irritation,  photopho- 
bia and  slight  pain.  In  other  cases  all  such  premonitary  symp- 
toms are  wanting.  The  next  symptom  is  the  appearance  of  a 
grayish  spot  lying  usually  in  the  middle  or  deeper  lamellae  of 
of  the  cornea.  This  may  appear  at  the  corneo-scleral  margin 
and  gradually  spread  over  the  whole  cornea,  or  it  may  start  in 
the  center  of  the  cornea  and  gradually  spread  towards  its 
periphery.  The  spreading  may  take  place  by  the  appearance 
of  new  gray  spots  which  later  on  more  or  less  coalesce,  or  the 
original  gray  spot  may  simply  grow  in  size.  However,  even 
when  it  seems  to  be  one  solid  gray  spot,  it  can  be  seen  by  the 
aid  of  a  magnifying  glass,  that  in  reality  it  consists  of  numer- 
ous smaller  ones.  The  spreading  of  the  dimness  over  the  cor- 
nea usually  takes  from  several  weeks  to  several  months,  and  de- 
pends sortlewhat  on  the  severity  of  the  attack.  During  this 
period  the  epithelium  suffers,  too.  Its  natural  lustre  is  de- 
stroyed, and  it  looks  steamy  or  stippled  and  irregular. 

When  the  dimness  appears  first  at  the  corneo-scleral  margin 
it  may  be  soon  entered  by  a  bunch  of  small  blood-vessels 
coming  from  the  terminal  loops  of  the  corneal  periphery. 
These  vessels  follow  the  dimness  for  some  extent  into  the  cor- 
neal area.  Aside  from  these,  other  blood-vessels  (sometimes 
only  one,  apparently)  spring  from  the  scleral  vessels  and  grow 
into  the  infiltrated  portion.  In  some  cases  they  are  so  numer- 
ous that  at  the  height  of  the  process  the  cornea  appears  red- 
dish like  raw  flesh.  While  in  some  cases  the  deeper  tissues  of 
the  eye  are  not  affected,  in  others  hyperaemia  of  the  iris, 
iritis  and  irido-cyclitis  may  occur.  When  the  whole  of  the 
cornea  is  dim,  sight  may  be  almost  abolished.  When  the  dim- 
ness has  started  in  the  center  it  often  leaves  a  clear  space  at 
the  corneal  periphery,  which,  however,  is  useless  for  vision. 

While  the  symptoms  of  photophobia,  pain  and  lachrymation 
are  quite  prominent  in  some  cases,  they  are  tnild  and  totally 
absent  in  others. 

After  the  disease  has  been  at  its  height  for  some  time,  the 
cornea  in  some  place    near  its    periphery   begins  to  clear  up. 


126  OPHTHALMOL  OGY. 

Other  peripheral  portions  follow  suit  and  finally  the  center 
also  gets  clearer  and  clearer,  until  but  barely  a  thin  cloudiness 
or  not  even  this  is  visible  to  the  naked  eye.  During  and  after 
this  clearing  process  the  newly  formed  blood-vessels  also  dis- 
appear, at  least  to  the  naked  eye.  With  a  magnifying  lens, 
even  in  the  apparently  perfectly  clear  cornea,  some  dimness 
and  fine  branches  of  blood-vessels  may  be  recognized  many 
years  after  an  attack  of  parenchymatous  keratitis  {Hirschberg). 
Sight,  in  spite  of  this,  is  nearly  normal. 

In  rare  cases  the  infiltration  may  lead  to  pus  formation  (ab- 
scess or  ulcer)  and  even  to  perforation  of  the  cornea,  and  I 
have  seen  an  anterior  polar  cataract  to  result  from  such  an 
occurrence.  In  other  rare  cases  the  cornea  gives  way  to  the 
intraocular  pressure  and  is  bulged  out. 

Sometimes  the  cornea  does  not  clear  up  as  well  as  above 
described.  In  these  cases  the  infiltration  has  led  to  the  form- 
ation of  scars  (connective  tissue)  and  sclerosis  of  the  cornea. 
When  such  a  sclerosis  has  taken  place  in  the  whole  area  of  the 
cornea,  this  membrane  grows  flatter  and  anterior  phthisis  of 
the  eyeball  may  follow.  According  to  the  situation  of  such  a 
scar  or  scars,  vision  may  be  partially  or  very  greatly  impaired. 
In  such  cases  an  artificial  pupil  may  still  be  the  means  of  giv- 
ing the  patient  useful  vision. 

Parenchymatous  keratitis  is  always  a  chronic  and  tedious 
affection.  There  are  variations  in  the  severity  of  the  attack, 
but  on  an  average  it  takes  from  three  to  six  months  to  run  its 
course;  some  cases  take  much  longer.  The  duration  of  the 
affection  may,  however,  be  shortened  by  intelligent  treatment, 
especially  if  the  case  is  seen  at  its  beginning. 

The  disease  may  attack  one  eye  alone,  but,  as  a  rule,  the 
other  eye  is  also  invaded  by  it.  However,  both  eyes  are  not 
frequently  attacked  at  the  same  time;  there  may  be  even  an 
interval  of  one  or  several  }  ears  between  the  affection  of  the 
first  and  that  of  the  second  eye.  It  is  more  frequently  seen 
in  children  than  in  adults. 

Through  the  influence  of  Hutchinson! s  researches  it  has  be- 
come the  rule,  particularly  with  the  English  authors,  to  call 
this  form  of  keratitis  simply  syphilitic  keratitis,  hereditary 
syphilis  being   looked    upon    as  its  sole  cause.      The    fact   is 


DISEASES  OF  THE  CORNEA.  127 

unquestioned  that  a  large  number  of  the  patients  suffering 
from  this  disease  show  evidences  of  inherited  syphilis,  as 
Hutchinson's  teeth,  scars  at  the  angles  of  the  mouth,  en- 
larged lymphatic  glands,  partial  loss  of  hearing  and  others, 
yet  the  affection  is  also  observed  in  quite  a  number  of  cases 
in  which  no  such  characteristic  symptoms  are  found.  Some 
of  these  patients  may  be  of  a  strumous  or  an  otherwise  en- 
feebled and  anaemic  constitution,  others  appear  to  be  perfectly 
healthy.  Occasionally  parenchymatous  keratitis  is  met  with 
in  cases  of  acquired  syphilis. 

The  prognosis  with  regard  to  the  clearing  up  of  the  corneal 
dimness  is  rather  good,  and  is  the  better  the  greater  the  vas- 
cularization of  the  dim  cornea.  The  local  treatment,  there- 
fore, must  include  chiefly  such  remedies  as  are  likely  to  bring 
about  and  stimulate  the  new  formation  of  blood-vessels  in  the 
corneal  tissue.  This  is  most  successfully  accomplished  by  the 
frequent  application  of  moist  heat.  Hot  bathing  of  the  closed 
eye  three  or  four  times  during  the  day,  for  from  half  an  hour 
to  an  hour  at  the  time  should  at  once  be  ordered.  In  its  place 
steam  from  an  atomizer  may  be  used.  If  there  is  photophobia, 
smoked  glasses  are  to  be  worn.  To  prevent  or  render  less 
nocuous  any  iritic  complications,  atropine  must  be  instilled. 
In  order  to  hasten  the  recuperative  process  mild  massage  with 
an  ointment  of  yellow  oxide  of  mercury  (two  to  four  per  cent.) 
once  a  day  is  highly  to  be  recommended.  The  cornea  may 
be  slightly  touched  with  sulphate  of  copper,  iodoform  or 
calomel  may  be  dusted  into  the  eye,  although  in  my  experience 
these  remedies  have  not  given  any  better  satisfaction.  In  the 
later  stages  and  in  obstinate  cases  I  have  seen  good  effects 
from  the  instillation  of  a  two  per-cent.  solution  of  creoline 
(which,  however  is  very  painful)  and  from  the  application  of 
the  galvanic  current.  Subconjunctival  injections  of  a  few 
drops  of  a  one  per  mille  solution  of  bichloride  of  mercury  in 
cases  in  which  syphilis  is  undoubted  seem  rational  and  are 
highly  recommended. 

To  this  local  treatment  constitutional  treatment  must  be 
added,  where  it  is  called  for,  and  it  may  be  well  in  all  cases 
to  give  some  tonic  or  iodide  of  potassium.  It  must,  however  be 
kept  in  mind,    that  whenever  an  iodide  is  exhibited  internally 


128  OPHTHALMOL  OGY. 

it  is  secreted  with  the  tears,  and  for  that  reason  no  calomel 
must  be  applied  to  the  eye,  as  it  would  cause  the  formation  of 
the  iodide  of  mercury,  which  produces  undue  irritation  or  even 
caustic  effects. 

^^J.  When  an  infiltration  of  the  cornea  and  a  local  necrosis 
lead  to  the  formation  of  pus  within  the  corneal  tissue  we  call  it 
an  abscess  of  the  cornea. 


Fig.  44. — Abscess  of  the  cornea  with  hyopyon  (hypopyon-keratitis). 

This  affection  appears  always  in  an  acute  form.  We  see  in 
the  cornea  a  dim  yellowish  spot,  which  may  be  near  the  sur- 
face or  lie  embedded  in  the  deeper  layers.  It  is  usually  round 
or  semilunar,  or  it  may  be  ring-shaped.  Its  outlines  are, 
however,  never  very  sharply  defined,  as  the  surrounding 
tissue  is  also  in  a  state  of  infiltration.  If  the  affection  progresses 
the  nearest  surrounding  parts  become  also  necrosed.  When 
such  an  abscess  has  reached  a  certain  size,  pus  cells  will  wan- 
der from  it  into  the  anterior  chamber  and  there  fall  to  the 
lowest  point,  and  form  what  is  called  hypopyon.  (See  Fig.  44). 
In  the  formation  of  this  hypopyon  the  iris  and  ciliary  body, 
which  frequently  become  also  inflamed,  may  take  a  part.  The 
aqueous  humor  becomes  generally  turbid.     The  abscess  may. 


DISEASES  OF  THE  CORNEA.  129 

furthermore,  increase  so  as  to  break  through  the  anterior  sur- 
face, and  thus  form  an  ulcer.  Sometimes  it  breaks  through 
into  the  anterior  chamber.  The  pus  may  also  become  ab- 
sorbed with  or  without  the  newformation  of  blood-vessels. 
The  cavity  of  the  abscess  is  then  filled  with  newformed  con- 
nective tissue  and  a  gray  spot  will  be  left  to  mark  its  former 
location.  In  very  rare  cases  the  pus  ^is  absorbed  without  any 
newformation  of  connective  tissue,  or  at  least  with  not  enough 
to  fill  the  cavity.  On  the  other  hand  the  abscess  may  cause  per- 
foration of  the  whole  thickness  of  the  cornea  and  lead  to  ante- 
rior synechia,  loss  of  the  crystalline  lens  and  vitreous  body, 
staphyloma,  and  total  loss  of  the  eye. 

Abscess  of  the  cornea  is  a  very  painful  affection,  the  pain 
being  apparently  greatest  at  night  and  keeping  the  patient 
from  sleeping.  There  is  great  irritation,  photophobia  and 
lachrymation.  The  disease  appears,  as  a  rule,  in  one  eye  only. 
It  is  seen  more  frequently  in  old  and  debilitated  individuals 
than  in  young  persons.  It  is  due  to  a  pyogenous  infection  of 
the  cornea  and  frequently  occurs  after  slight  injuries  to  this 
membrane  (with  subsequent  pyogenous  infection),  especially 
when  there  is  a  pre-existing  affection  of  the  tear-passages. 

The  prognosis  in  this  affection  is  always  doubtful,  as  we 
cannot  predict  how  far  the  process  will  extend.  As  a  rule, 
however,  its  progress  stops  when  the  abscess  has  perforated 
the  surface.  If  there  is  a  great  quantity  of  pus  in  the  anterior 
chamber,  the  prognosis  is,  of  course,  more  doubtfel  than  if 
there  is  little  or  none. 

The  treatment  consists  in  hot  moist  applications  to  the 
closed  eye,  as  hot  as  the  patient  can  bear  them.  This  and  the 
instillations  of  cocaine  will  help  to  relieve  the  otherwise  often 
excruciating  pain.  To  prevent  iritis  atropine  should  be  in- 
stilled. Instead  of  the  instillations  of  atropine,  eserine  has  of 
late  been  used  frequently,  but  seems  to  have  not  only  no  ad- 
vantage over  the  atropine  but  it  even  seems  to  favor  the  for- 
mation of  iritis. 

If,  under  this  treatment,  the  pain  and  the  process  of  the 
affection  do  not  stop,  and  voluntary  rupture  or  absorption  do 
not  readily  occur,  I  have  seen  great  and  immediate  benefit, 
not  from  opening  the  anterior  chamber,  as  many  do,    but  from 


130  OPHTHALMOLOGY. 

cutting  simply  through  the  layers  anteriorly  to  it  into  the 
cavity  of  the  abscess  and  allowing  the  pus  to  escape,  just  as 
one  would  open  an  abscess  elsewhere.  SaemiscK s  method, 
which  is  frequently  practised,  consists  in  cutting  through  the 
whole  thickness  of  the  cornea  about  in  the  middle  line  of  the 
abscess,  and  letting  the  aqueous  humor  and  pus  escape  through 
this.  The  incision  should  begin  and  end  in  healthy  tissue,  and 
must  be  reopened  from  day  to  day  until  the  formation  of 
pus  ceases.  This  method  is  very  painful,  does  not  give 
quick  results,  and  in  the  end  the  case  often  does  no  better 
than  it  would  have  done  with  less  interference;  anterior  sy- 
nechia, moreover,  follows  very  frequently.  The  simple  opening 
of  the  abscess  is  more  rational  and  fully  as  effective. 

The  most  rational  method  is  to  destroy  the  anterior  wall  of 
the  abscess  and  the  seat  of  the  abscess  itself  by  galvano- 
cautery.  This  must  be  followed  by  instillations  of  a  solution 
of  bichloride  of  mercury  (or  the  inspergation  of  iodoform,  or 
the  instillation  of  a  solution  of  pyoctanine)  and  closure  of  the 
eye.  Thus  we  may  succeed  in  rendering  and  keeping  the 
affected  territory  aseptic,  and  to  put  it  in  the  best  conditions 
for  a  rapid  healing.  If  carefully  done  the  cauterization  arrests 
the  spreading  of  the  abscess  and  will  leave  no  greater  scar, 
than  the  abscess  would  have  left. 

If  there  is  a  lachrymal  affection  present  it  must,  of  course, 
be  attended  to. 

§68.  Ulcers  of  the  cornea  are  either  caused  by  a  previous 
abscess  in  the  way  just  described,  or  the  infiltration  is  at  first 
superficial,  leading  presently  to  necrosis  of  the  epitheHum  and 
most  superficial  layers  of  the  cornea. 

They  are  due  to  the  presence  of  a  micro-organism,  mostly 
of  a  pyogenous  character,  without  a  preceding  traumatism,  or 
following  one.  Corneal  ulcers  are  among  the  most  frequent 
affections  of  the  eye  and  vary  greatly  as  to  situation,  form 
and  progress.  They  may  come  on  when  there  is  no  other  eye- 
affection  present,  or  they  may  be  directly  due  to  another 
affection  of  the  eye,  particularly  to  diseases  of  the  con- 
junctiva,   trichiasis   and    entropium.     The  ulcer  may  make  its 


DISEASES  OF  THE  CORNEA. 


131 


appearance  at  the  center  or  at  the  periphery  of  the  cornea,  or 
at  any  intermediate  portion.     (See  Fig.  45). 


Fig.  45. — Histological  appearance  of  an  ulcer  of  the  cornea.  Its  ground  and  walls 
are  infiltrated  with  round  cells.  The  epithelium  surrounding  its  margin 
is  in  a  state  of  proliferation. 

As  long  as  the  ulcer  is  progressing  its  walls  and  fundus,  as 
well  as  the  surrounding  parts,  are  grayish  or  yellow  from  in- 
filtration. The  pus  cells  may  also  invade  the  anterior  chamber 
and  form  a  hypopyon.  Iritis  is  also  a  frequent  complication. 
When  the  ulcer  heals,  its  walls  and  fundus  first  become  clear, 
and  then,  with  or  without  the  formation  of  blood  vessels  in  the 
cornea,  the  process  of  repair  begins.  The  ulcer  is  gradually 
filled  up  with  new-formed  translucent  connective  tissue,  which 
becomes  covered  by  epithelium,  thus  leaving  behind  it  a  gray 
spot.  Often  the  progress  of  the  ulcer  does  not  stop  until  it 
has  gradually  eaten  through  the  whole  thickness  of  the  cornea 
and  caused  a  perforation.  Before  this  occurs,  Descemet's  mem- 
brane, which  is  very  resistent,  may  sometimes  be  seen  to 
bulge  forward  through  the  ulcerated  part  (keratocele)  for 
some  time.  When  the  perforation  takes  place  the  aqueous 
humor  escapes,  the  iris  prolapses  into  the  corneal  wound,  and 
the  ulcer  may  heal  with  an  anterior  synechia.  If  the  perforation 
takes  place  in  the  center  of  the  cornea  the  anterior  capsule  of 
the  crystalline  lens  comes  in  contact  with  the  ulcer  and  plugs 
it.  This  may  give  rise  to  the  formation  of  an  anterior  polar 
cataract.     In  other  cases  these  accidents  may  lead  to  the  loss 


132  OPHTHALMOLOGY. 

of  the  crystalline  lens,  and  even  of  the  vitreous  body,  to  the 
formation  of  a  partial  or  total  corneal  staphyloma,  or  to  loss 
of  the  eye  through  shrinkage.  In  rare  cases  the  loss  of  sub- 
stance by  ulceration  is  not  repaired  and  its  site  is  covered 
with  epithelium  only  {fascette). 

Like  abscesses  of  the  cornea,  ulcers  are  usually  very  painful, 
and  cause  photophobia  and  lachrymation. 

Their  occurence  is  not  particularly  confined  to  any  period  of 
Hfe.  They  frequently  appear,  as  has  already  been  stated, 
during  conjunctival  affections.  Corneal  phlyctaenula  and 
ulcers  occur  also  in  connection  with  malarial  fever,  and  a  par- 
ticular form  of  ulcer  has  been  described  as  malarial  keratitis 
(Kipp  and  others). 

The  prognosis  is  doubtful  and  depends  on  the  size  and  local- 
ity of  the  ulcer. 

The  most  rational,  quick  and  efficient  way  of  treating  a 
corneal  ulcer  is  by  galvano-cautery  (or  actual  cautery). 
Cocaine  renders  this  little  operation  almost  painless.  Care 
must  be  taken  to  cauterize  the  whole  ulcerated  surface,  even 
should  a  perforation  occur.  This  is  to  be  followed  by  the  in- 
stillation of  a  solution  of  bichloride  of  mercury  or  pyoktanine, 
or  by  the  inspergation  of  iodoform,  or  similar  antiseptic  reme- 
dies, and  closure  of  the  eye  by  a  bandage  or  plaster.  The  cau- 
terization destroys  the  injurious  germs  and  is  at  the  same  time 
an  excellent  stimulus  to  the  newformation  of  tissue  which  is  to 
replace  the  lost  tissue.  Pure  carbolic  acid  may  take  the  place 
of  the  galvano-cautery. 

Very  small  superficial  ulcers  may  be  treated  by  means  of  hot 
bathing  or  steaming  of  the  closed  eye,  flushing  with  a  solution 
of  bichloride  of  mercury  or  ofboracic  acid,  or  inspergations  of 
iodoform,  and  gentle  massage  with  an  ointment  of  aristol  or 
yellow  oxide  of  mercury.  It  may  be  advantageous  to  keep  the 
eye  closed  with  a  bandage  or  plaster  in  the  intervals  between 
the  local  application,  and  it  may  be  necessary  to  keep  the 
pupil  dilated  by  the  instillation  of  atropine. 

It  is  the  duty  of  every  practitioner  to  avoid  and  prevent  the 
use  of  any  eye-wash  or  bathing  lotion  containing  acetate  of 
lead,  a  practice  which  is  still  too  common  in  this  country. 
When  such   lotions   are   applied  to  the  ulcerated  cornea,  in- 


DISEASES  OF  THE  CORNEA.  133 

crustations  of  lead  take  place  on  this  membrane,  which  inter- 
fere greatly  with  vision  and  can  frequently  not  be  removed 
later  on. 

Whenever  it  is  for  some  reason  impracticable  to  cut  short 
the  process  of  ulceration  by  means  of  the  galvano-cautery  and 
the  ulcer  refuses  to  cleanse  itself,  and  continues  to  invade  new 
territory  and  causes  the  formation  of  hypopyon,  the  operation 
introduced  by  Saemisch  is  applicable  and  is  here  of  greater 
utility  than  in  cases  of  abscess  of  the  cornea.  Care  must  be 
taken  to  begin  and  end  the  cut  in  the  healthy  tissue,  as  far  as 
this  may  yet  be  possible. 

In  other  cases  simple  paracentesis  of  the  cornea  will  be  suf- 
ficient, or  an  iridectomy  may  be  called  for,  as  the  intra-ocular 
pressure  is  sometimes  increased  (secondary  glaucoina). 

Ulcers  complicating  a  conjunctival  inflammation  seldom 
need  special  treatment.     (See  Chapter  VII). 

In  paralysis  of  the  trigeminus,  ulcerations  (sometimes  ab- 
scesses) of  the  cornea  are  often  observed.  These  cases  are 
easily  recognized  from  the  fact  that  the  sensibility  of  the  cor- 
nea is  greatly  reduced  or  totally  abolished.  Usually  the  se- 
cretion of  tears  and  of  mucus  is  also  diminished  and  thus  a  dry- 
ness of  the  corneal  epithelium  results.  The  reduced  sensibility 
makes  it  possible  for  small  foreign  bodies  to  wound  the  cornea 
or  even  remain  on  it,  without  apparently  causing  discomfort. 
The  reduced  secretion  of  tears  in  itself  gives  rise  to  superficial 
excoriations. 

Similar  ulcers  occur  in  facial  palsy,  Basedow's  (Graves')  dis- 
ease, during  the  semi-unconscious  state  of  febrile  diseases, 
when  reflex  winking  is  abolished,  or  when  from  whatever  cause 
the  upper  eyelid  cannot  protect  the  cornea  from  air,  heat, 
dust  and  micro-organisms. 

If  it  is  impossible  to  cure  the  paralysis  of  the  trigeminus, 
or  to  remove  the  disability  of  the  upper  lid  to  protect  the 
cornea  by  any  other  means,  this  must  be  done  by  shortening 
the  palpebral  fissure  by  the  operation  of  tarsorraphy.  (See 
Chapter  III.). 

§69.  As  has  already  been  stated,  any  process  in  the  cornea 
which  is  attended  with  destruction  of  tissue  and  which  neces- 


134 


OPHTHALMOL  OGY. 


sitates  repair  by  means  of  newly  formed  connective  tissue, 
must  result  in  a  scar.  Scars,  in  contrast  with  the  normal,  trans- 
parent corneal  tissue,  are  only  translucent,  and  therefore  ap- 
pear as  more  or  less  dense  grayish,  or  even  white  spots  which 
according  to  their  situation,  may  or  may  not  interfere  with 
vision;  when  large  and  centrally  placed  they  may  render  the 
eye  partially  or  even  practically  blind  by  their  density,  or  they 
may  give  rise  to  irregular  astigmatism,  by  altering  the  curva- 
ture of  the  cornea.     (See  Fig.  46). 


Fig.  46. — Histological  appearance  of  a  healed  ulcer  of  the  cornea  (leucoma).  The 
former  loss  of  substance  is  filled  with  new  formed,  irregularly  arranged 
and  but  semi-transparent  connective  tissue.  Bowman's  layer  being  ab- 
sent, the  epithelium  has  grown  downward  into  the  scar-tissue. 


These  scars  may  clear  up  to  a  certain  extent,  especially  when 
situated  superficially,  and  particularly  in  children's  eyes.  This 
process  of  clearing  may  sometimes  be  very  beneficially  influ- 
enced by  treatment.  Gentle  massage  with  an  ointment  contain- 
ing yellow  oxide  of  mercury,  or  iodide  of  potassium,  or  blue  oint- 
ment, the  instillation  of  tincture  of  opium  diluted  with  water, 
and  spraying  the  cornea  with  steam  or  solutions  of  sulphate  of 
copper  or  of  tannic  acid,  have  been  recommended  and  are  in 
in  some  cases  beneficial. 

In  certain  cases  patients  suffer  from  very  annoying  dazzHng 
from  light,  which  is  irregularly  refracted  in  passing  through 
such  a  translucent  scar,  especially  if  it  covers  only  a  part  of  the 
pupillary  area.  In  such  cases  it  is  sometimes  advisable  to 
tatoo  the  scar   with  India  ink   so  as  to  render  it  impermeable 


DISEASES  OF  THE  CORNEA,  135 

to  light.  Tatooing  may  also  be  used  for  a  simply  cosmetic 
effect,    when  a  scar  of  the  cornea  is  very  disfiguring. 

When  the  scar  lies  in  front  of  the  whole  pupillary  area,  and 
renders  the  patient  virtually  blind,  an  iridectomy  may  often 
restore  useful  vision.  This  should  be  made  preferably  in  a 
place  where  the  upper  eyelid  is  not  likely  to  cover  it,  but  the 
direction  of  the  iridectomy  is  usually  determined  by  the  posi- 
tion of  the  clearest  and  best  part  of  the  remaining  cornea,  and 
thus  may  have  to  be  made  where  the  surgeon  would  least 
desire,  were  he  left  free  in  his  choice.  An  iridectomy  for 
this  purpose  should  be  made  as  small  as  possible,  as  the  patient 
will  see  better  through  a  small  pupil,  which  does  not  allow 
many  irregularly  refracted  rays  to  enter  the  eyeball,  than 
through  a  larger  one  which  admits  them. 

The  grayish  zone  seen  in  the  periphery  of  the  cornea, 
usually  in  people  of  an  advanced  age,  is  called  the  arcus 
senilis.  It  is  not  scar-tissue,  but  the  result  of  a  fatty  degenera- 
tion of  the  corneal  tissue  and  cells,  and  is  of  no  importance. 


Fig.  47. — Staphyloma  of  the  cornea.     On  the  right  hand  iris  and  cornea  are  firmly 
attached  to  each  other,  atrophied  and  stretched. 

As  has  been  before  stated,  an  abscess  and  ulcer  of  the 
cornea,  which  leads  to  perforation,  may  result  in  the  for- 
mation of  a  staphyloma.  The  staphyloma  consists  in  a  partial 
or  total  bulging  of  the  remains  of  the  cornea  together  with  the 
iris,  which  in  these  cases  always  adheres  to  it.  If  left  alone, 
the  bulging  process  may  go  on  until  the  eyelids  can  no 
longer  be  closed  over  the  eyeball.  Such  eyes  are  seldom 
free  from  irritation,  and  they  are  liable  to  be  attacked  by 
various  forms  of  inflammation;  sometimes  a  secondary  glau- 
coma results.     (See  Fig.  47). 

In  the  beginning  of  a  partial  staphyloma  the  instillation  of  a 


136  OPHTHALMOLOGY. 

solution  of  eserine  or  pilocarpine,  and  frequent  puncturing  of 
the  bulging  tissue  may  be  successfully  resorted  to.  The  latter 
procedure  causes  more  and  more  scar  tissue  to  be  formed,  which 
by  its  shrinking  often  brings  about  a  flattening  of  the  protrud- 
ing parts.  Sometimes  an  iridectomy  or  sclerotomy  proves 
successful  in  these  cases,  combined  with  the  application  of  a 
compressive  bandage.  I  some  cases  when  the  staphyloma  is 
very  small  it  may  be  best  to  cut  or  burn  a  part  of  it  away  with 
the  galvano-cauter. 

To  remove  a  total  staphyloma  of  the  cornea  an  abscision  of 
the  whole  cornea  may  be  made,  combined  with  the  removal 
of  the  crystalline  lens,  if  it  is  still  present.  The  margin  of 
the  opening  thus  left  in  the  sclerotic  will  generally  heal  to- 
gether, and  a  good  stump  on  which  an  artificial  eye  can  be 
worn  is  the  result. 

To  hasten  the  closure  of  the  wound  Critchett  stitched  the 
scleral  wound-lips  together,  the  needles  passing  through  the 
ciliary  body.  Knapp  improved  on  this  procedure  by  suturing 
the  conjunctiva  only,  the  threads  acting  like  the  strings  of  a 
tobacco-pouch. 

In  modern  times  evisceration  of  the  eyeball,  emptying  it  of 
all  its  contents  with  a  sharp  spoon  and  subsequent  insertion  of 
a  glass  ball  {Mules)  have  been  recommended  in  order  to  im- 
prove the  stump  left  after  abscision  of  the  staphyloma. 

Still,  as  any  such  stump  may  become  inflamed,  and  cause 
sympathetic  inflammation  of  the  good  eye,  it  is  better,  as  a 
rule,  to  remove  every  eye  with  total  staphyloma  of  the  cornea, 
whenever  the  case  cannot  be  kept  under  continued  observation. 

When  the  whole  of  the  corneal  tissue  is  changed  to  scar  tis- 
sue and  no  perforation  has  occurred,  it  may  still  be  possible  to 
restore  some  sight,  by  the  implantation  of  a  transparent  flap 
of  corneal  tissue  {Hippel).  In  order  to  do  this  a  disc  of  opaque 
corneal  tissue  is  removed  by  means  of  a  trephine  down  to 
Descemet's  membrane,  which  latter  must  remain  intact.  Into 
this  gap  a  disc  of  transparent  cornea  is  transplanted,  and  may 
remain  transparent  enough  to  allow  of  some  useful  vision. 

Conical  cornea,  a  cone-shaped  bulging  of  one  or  both  corneae, 
may  be  the  result  of  the  loss  of  resisting  power  with  or  without 


DISEASES  OF  THE  CORNEA.  137 

previous  ulceration  and  gradual  thinning  out  of  the   corneal 
tissue.     (See  Fig.  48). 


Fig.  48.— Keratoconus. 

The  abnormal  refraction  which  by  the  gradual  increase  of 
the  cone  gets  worse  and  worse,  disturbs  vision  very  consid- 
erably. Hyperbolic  glasses  may  sometimes  be  worn  with  suc- 
cess by  such  patients  [Rcehlmaiin).  Dor  recommends  contact 
lenses.  The  production  of  a  retracting  scar  by  cauterizing  the 
cone  at  its  apex,  or  the  excision  of  the  apex,  has  sometimes 
had  a  beneficial  effect  on  the  sight  of  eyes  so  affected. 

§70.  Injuries  to  the  cornea  are  of  frequent  occurrence.  Very 
frequentiy  they  are  complicated  by  injuries  to  the  deeper  parts 
of  the  eyeball.  When  the  cornea  alone  is  injured  the  condi- 
tions are  comparatively  simple.  In  all  such  cases  it  is  neces- 
sary to  establish  as  soon  as  possible  a  condition  of  relative 
asepsis  by  all  means  at  our  hand,  even  the  galvano- cautery, 
and  to  maintain  it. 

Injuries  may  be  inflicted  by  blunt  or  by  cutting  instruments, 
by  heat,  or  by  chemicals. 

Abrasions  of  the  corneal  epithelium  are  often  seen.  They 
are  painful  and  cause  lachrymation,  especially  when  the  eye- 
ball is  moved.  Flushing  with  an  antiseptic  solution,  instillations 
of  atropine  and  cold  or  warm  applications  with  rest,  which  may 
be  brought  about  by  a  compressive  bandage,  will  allay  the 
disagreeable  symptoms,  and  the  defect  will  generally  be  healed 
in  from  one  to  two  days. 

Aseptic  cuts  that  do  not  penetrate  the  whole  thickness  of 
the  cornea  heal  very  readily. 


138  OPHTHALMOL  OGV. 

When  the  corneal  tissue  is  perforated  by  the  injuring  body, 
just  as  in  the  case  of  a  perforating  ulcer  or  abscess,  the  aque- 
ous humor  will  escape,  ^  and,  as  the  posterior  parts  are  thus 
moved  forward  by  the  intra-ocular  pressure,  the  iris  may  be 
caught  between  the  wound-lips,  or  it  may  even  prolapse 
through  them,  and  be  held  in  that  position.  As  prolapse  of 
the  iris  increases  the  danger  to  the  eye,  and  may  even  be  the 
means  of  exciting  inflammation  of  the  uveal  tract  or  the  forma- 
tion of  staphyloma,  the  iris  should,  if  possible,  be  set  free.  If 
it  is  impossible  to  cause  its  retraction  by  slightly  rubbing  the 
cornea  with  the  eyelids,  by  the  instillation  of  the  sulphate  of 
atropia  or  of  eserine,  or  by  instrumental  help,  the  last  resort  is 
to  cut  off  the  protruding  part  and  thus  permit  the  remainder 
of  the  iris  to  retract  within  the  eye.  Some  surgeons  suture 
the  corneal  wounds.  Burns  of  the  cornea  by  hot  for- 
eign bodies  or  by  chemicals,  especially  lime,  cause  a  more 
or  less  superficial  necrosis  of  the  corneal  tissue  with  sub- 
sequent ulceration.  When  the  cornea  alone  is  injured,  the 
treatment  will  be  the  same  as  in  the  case  of  a  cut  of  the  cor- 
nea, except  when  the  burn  resulted  from  lime.  In  this  case 
every  particle  of  lime  should,  if  possible  be  removed  and  the 
remainder  neutrahzed  by  acidulated  water  (vinegar).  It  some- 
times happens  that  we  find  a  shell  of  lime  lying  on  the  cornea 
after  all  inflammatory  symptoms  have  passed  off.  It  may  be 
possible  to  remove  this,  and  the  patient's  sight  may  thus  be 
greatly  improved. 

When  the  burning  material  has  at  the  same  time  injured  the 
conjunctiva  there  is  danger  of  the  formation  of  asymblepharon, 
which  must,  if  possible,  be  prevented.  This  point  has  already 
received  the  necessary  attention.     (See  Chapter  VII). 

The  tumors  of  the  cornea  take  their  origin  almost  invariably 
from  the  adjacent  conjunctival  tissue,  and  therefore  only  sec- 
ondarily invade  the  corneal  tissue.  They  have  been  spoken  of 
in  Chapter  VII. 


CHAPTER     IX.— DISEASES     OF     THE     SCLEROTIC. 

The  sclerotic  proper  is  not  very  apt  to  become  inflamed,  and 
such  inflammatory  symptoms  as  sometimes  occur  in  it  take 
their  origin  probably  in  the  episcleral  tissue. 

§71.  Episcleritis,  or  scleritis,  usually  affects  but  one  eye  at 
the  time  and  is  a  localized  inflammation.  Near  the  limbus  of 
the  cornea  and  beneath  the  highly  hyperaemic  conjunctiva,  a 
purple  elevation  is  seen,  which  is  often  painful  and  tender  on 
pressure.  The  deeper  the  seat  of  the  inflammation  the  deeper 
is  the  purple  color.  Although  beginning  as  a  small  localized 
tumor,  the  swelling  often  wanders  around  the  whole  periphery 
of  the  cornea.  Episcleritis  may  run  its  course  without  further 
complication,  or  it  may  be  complicated  with  affections  of  the 
cornea,  iris,  choroid  and  even  of  the  retina.  It  is  a  tedious 
disease,  often  resists  treatment  for  a  long  period,  and  is  very 
apt  to  recur. 

The  reason  for  these  peculiarities  lies  in  the  fact  that  its  oc- 
currence is  mostly  due  to  some  general  diathesis,  rheumatism, 
gout,  or  syphilis  being  present  in  the  majority  of  cases.  An- 
other class  of  cases  occur  in  females  at  the  climacteric  period, 
or  when  suffering  from  some  trouble  of  the  sexual  organs. 
Episcleritis  is  also  occasionally  due  to  an  injury,  in  which  case 
it  yields  more  readily  to  treatment  than  when  it  is  of  consti- 
tutional origin.  The  direct  cause  of  the  non-traumatic  cases 
of  episcleritis  is,  as  Mooren  states,  probably  a  pathological 
condition  of  the  blood-vessels  brought  about  by  some  diathesis. 

The  treatment  which  appears  to  be  most  successful  consists 
in  hot  bathing,  instillations  of  atropine  and  the  use  of  an  oint- 
ment of  aristol  or  yellow  oxide  of  mercury  combined  with 
massage.  In  cases  of  syphilitic  (gummatous)  episcleritis  in- 
spergations  of  calomel  and  sub -conjunctival  injections  of  a  so- 
lution of  bichloride  of  mercury  seem  to  act  better  than  any 
other  remedy. 

—139— 


140  OPHTHALMOL  OGY. 

Whenever  a  general  diathesis  is  present  its  treatment  must 
accompany  the  local  applications. 

In  a  lew  cases  that  have  come  under  my  observation  at  a 
very  early  stage,  the  use  of  the  muriate  of  pilocarpine,  either 
hypodermically  or  instilled  into  the  eye,  has  been  followed  by 
a  remarkably  rapid  recovery.  It  has  been  recommended  also 
to  cut  trough  the  swollen  part  down  to  the  healthy  sclerotic, 
or  even  to  scrape  the  whole  swelling  off  with   a  sharp  curette. 

§72.  There  is  an  insidious  chronic  form  of  scleritis  affecting 
the  deeper  layers  of  the  sclerotic  and  complicated  with  inflam- 
mation of  the  uveal  tract,  which  is  for  the  most  part  noticed 
by  its  results  only,  namely,  the  formation  of  a  scleral  staphy- 
loma.  Such  a  stayhyloma  forms  a  bluish  elevation  which 
usually  begins  at  one  of  the  weaker  parts  of  the  sclerotic,  es- 
pecially where  it  is  pierced  by  blood-vessels,  and  may  gradu- 
ally grow  to  a  considerable  size.  The  seats  of  predilection  of 
scleral  staphyloma  are  in  the  equatorial,  or  the  ciliary  region 
of  the  eyeball.  In  some  cases  the  whole  sclerotic  may  become 
staphylomatous  {total  staphyloma). 


Fig.  49. — Ciliary  staphyloma  of  the  sclerotic.    The  atrophied  ciliary  body   adheres 
to  the  sclerotic  and  the  two  are  together  bulged  outward. 

At  the  seat  of  the  staphyloma  the  sclerotic  and  uveal  tract 
are  firmly  adherent  to  each  other,  and  become  together  more 
and  more  attenuated  and  stretched.  Although  the  disease 
may  at  first  interfere  comparatively  little  with  vision,  it  leads 
gradually  to  further  alterations  in  the  tissues  of  the  eyeball, 
and  frequently  gives  rise  to  secondary  glaucoma,  or  perhaps, 
ultimately  to  sympathetic  inflammation  of  the  fellow-eye. 
Scleral  staphyloma  is  sometimes  caused  by  an  injury,  but  in 
most  cases  the  etiology  is  obscure. 


DISEASES  OF  THE  SCLEROTIC.  141 

According  to  its  seat  we  distinguish  between  anterior  scle- 
ral staphyloma  {ciliary,  intercalary  staphyloma),  equatorial 
staphyloma  and  posterior  scleral  staphyloma.     (See  Fig.  49). 

The  last  form,  the  posterior  scleral  staphyloma,  is  due  to  an 
attenuation  and  stretching  of  the  sclerotic  adjoining  the  optic 
nerve  entrance  and  generally  in  the  direction  of  the  macula 
lutea.  As  in  this  form  of  staphyloma  there  is  always  elonga- 
tion of  the  antero-posterior  axis  of  the  eyeball,  myopia, 
(short-sightedness)  is  always  present.     (See  Fig.  50). 


Fjg.  50. — Posterior  staphyloma  of  the  sclerotic  Irom  a  myopic  eye.     Choroid  and 
sclerotic  adhere  to  each  other,  are  atrophied  and  bulged  outward. 

Total  staphyloma  of  the  sclera  (hydrophthalmus,  buphthalmus) 
is  due  to  the  thinning  and  stretching  of  the  whole  sclera, 
and  it  is  usually  combined  with  enlargement  of  the  cornea 
(megalocomea).  This  condition  may  be  congenital  or  acquired 
and  is  due  to  an  abnormally  high  intraocular  pressure  and  a 
weak  scleral  structure.  The  media  may  be  perfectly  clear.  In 
a  number  of  cases  the  cornea  is  dim,  or  the  iris  and  crystalline 
lens  are  adherent  to  each  other  and  pressed  forward  towards 
the  cornea  (probably  as  the  result  of  a  former  ulceration  and 
perforation  of  the  cornea)  and  there  may  be  signs  of  deeper 
inflammatory  processes.  Vision  accordingly  may  be  compar- 
atively useful  or  be  totally  abolished.  The  disease  may  be 
arrested  by  iridectomy,  or  removal  of  the  whole  iris  {Noyes)', 
in  some  cases  during  infancy  the  progress  stops  spontaneously. 
The  disease  may  attack  both  eyes,  but  occurs  often  in  one 
only. 

In  ciliary  and  aequatorial  staphyloma  when  they  are  not  too 
far  developed,  partial  abscision  or  an  iridectomy  may  some- 
times be  useful.     In  most  cases,  however,  the  time  for  such  an 


142  OPHTHALMOLOGY, 

operation  has  elapsed  before  the  patient  seeks  help.  If  such 
an  eye  is  irritable,  painful  and  unsightly  and,  as  is  mostly  the 
case,  is  useless  as  an  organ  of  vision,  it  is  best  to  enucleate  it. 

%'jl.  Wounds  and  ruptures  of  the  sclerotic  when  aseptic, 
may  heal  by  first  intention.  It  is,  however,  well  to  render 
the  eye  and  conjunctival  sack  as  aseptic  as  possible  by  anti- 
septic remedies,  and  then  to  either  stitch  the  conjunctival  and 
scleral  wound-lips  or  the  conjunctival  wound-lips  alone  togeth- 
er. Under  antiseptic  closure  the  healing  progresses  well  and 
may  leave  no  untoward  symptoms  behind.  I  have  even 
seen  extensive  complicated  wounds  of  the  sclerotic  with 
prolapse  of  the  choroid,  retina  and  vitreous  body,  heal  well 
and  apparently  give  no  further  trouble.  Yet,  as  the  wound- 
lips  and  deeper  parts  may  have  become  infected  when  the  in- 
jury occurred,  a  matter  which  we  have  no  means  immediately 
to  recognize,  such  complicated  wounds  must  be  looked  upon 
as  something  very  dangerous,  both  for  the  wounded  eyeball 
itself  and  its  fellow.  This  is  more  especially  the  case  when 
the  ciliary  region  is  involved.  The  physician,  should,  there- 
fore, be  extremely  guarded  in  giving  a  prognosis  in  such  cases. 

If  the  wound  is  due  to  a  small  foreign  body  which  is  retain- 
ed in  the  vitreous  body  it  should  be  removed  if  possible.  Par- 
ticles of  iron  or  steel  may  sometimes  be  successfully  removed 
by  means  of  a  magnet. 

When  a  deeper  infection  and  pus  formation  has  once  taken 
place  within  the  eye,  which  is  usually  due  to  the  presence  of 
some  septic  foreign  body  within  the  vitreous  body,  it  may  per- 
haps still  be  possible  to  remove  the  foreign  body  and  bring 
the  acute  inflammation  to  a  standstill,  yet  the  future  welfare  of 
such  eyes  is  always  doubtful. 

If  we  do  not  succeed  in  finding  the  foreign  body  and  in  re- 
moving it,  or  if  we  cannot  stop  the  progress  of  the  septic 
inflammation,  the  eyeball  should  be  removed.  This  is  the 
more  imperative  as  such  an  eye  is  a  continued  menace  to  the 
fellow-eye  by  inducing  sympathetic  {migratory)  ophthalmia. 
(See  Chapter  XVIII). 

Tumors  of  the  sclerotic  are,  as  a  rule,  of  conjunctival  origin; 
the  sclerotic  proper  is  seldom,  if  ever,  the  primary  seat  of  a 
new  formation. 


CHAPTER    X.-DISEASES     OF     THE    IRIS.       ' 

§74.  Inflammation  of  the  iris  is  a  rather  frequent  affection, 
and  is  easily  recognized  in  its  severer  forms  or  later  stages. 
It  is  chiefly  in  its  beginning  that  it  is  frequently  confounded 
with  catarrhal  conjunctivitis.*  It  may  be  well,  therefore,  to 
make  it  a  rule  to  dilate  the  pupil  by  instillation  of  a  one  per 
cent,  solution  of  sulphate  of  atropia  in  all  doubtful  cases. 

The  different  forms  of  iritis  are  chiefly  recognized  by  their 
products,  and  we  have  four  typical  forms,  namely:  plastic,  ser- 
ous, purulent,  gummatous  (and  tubercular)  iritis. 

Every  form  of  iritis  is  characterized  by  hyperaemia  of  the 
episcleral  blood-vessels,  and  secondarily  of  the  superficial  ves- 
sels of  the  ocular  conjunctiva. 

The  iris  loses  its  luster  and  is  changed  more  or  less  in  color 
(a  blue  iris  appearing  greenish),  a  change  which  is  most  easily 
recognized  when  only  one  eye  is  affected,  by  comparing  it 
with  the  fellow  eye.  Excepting  in  certain  cases  of  serous 
iritis,  the  pupil  is  small  and  immoveable. 

Except  in  slight  cases  every  attempt  to  open  the  eye  in  the 
light  is  attended  with  profuse  lachrymation,  and  generally  with 
sharp  pain.  Iritis  is,  as  a  general  rule,  a  very  painful  affec- 
tion, and  the  pain  is  usually  constant.  It  may  be  con- 
fined to  the  eyeball  itself,  or  it  may  irradiate  into  the  supra- 
orbital and  infra-orbital  regions;  it  is  usually  severer  at  night, 
and  is  often  extremely  distressing.  Besides  this  spontaneous 
pain  we  generally  find  that  the  eyeball  is  tender  on  pressure, 
which  shows  that  the  ciliary  body  is  also  implicated.  The 
eyelids  are  often  slightly  oedematous,  though  never  to  a  very 
high  degree,  except  in  purulent  iritis. 

Iritis  may  be  due  to  a  trauma,  but  is  more  frequently  a  spon- 
taneous disease. 

Spontaneous  iritis  generally  appears  in  one  eye  at  a  time, 
but  very  often  the  fellow  eye  is  attacked  while  the  disease  is 
still  active  within  the  first  eye. 

—143— 


144  OPHTHALMOLOGY. 

If  iritis  is  not  properly  treated  in  time,  it  always  leads  to 
attachments  between  the  iris  and  the  anterior  lens-capsule 
{^posterior  synechice).  These  are  easily  detected  by  the  instilla- 
tion of  atropia,  under  whose  action  the  pupil  will  assume  a 
very  irregular  shape,  according  to  the  number  and  extent  of 
the  synechiae.  (See  Fig.  51).  When  there  is  a  circular  at- 
tachment between  the  pupillary  margin  of  the  iris  and  the  an- 
terior iens-capsule,  the  pupil  will  remain  absolutely  unchanged 
(circular  synechia). 


Fig.  51. — Posterior  synechiae  in  plastic  iritis.     The  pupil  is  partially  dilated  by 
atropine. 

Vision  is  always  impaired  in  iritis,  although  to  a  varying  de- 
gree. This  is  dependent  on  the  size  of  the  pupil,  and  the 
quantity  and  quality  of  the  inflammatory  products  in  the  an- 
terior chamber,  and  on  the  anterior  lens-capsule.  Moreover, 
as  in  iritis  the  ciliary  body  and  choroid,  also,  are  hardly  ever 
free  from  inflammatory  activity,  exudations  from  these  parts 
into  the  vitreous  body  help  to  impair  vision.  Such  exu- 
dations are  frequently  observed  long  after  the  other  symptoms 
have  entirely  disappeared.  Some  forms  of  iritis  are  very  apt 
to  recur,  especially  when  it  has  been  impossible  to  break  all 
the  synechiae. 

§75.  \w  plastic  iritis  '^fibrinous,  rheumatic  iritis)  which  is  the 
most  frequent  form,  the  exudation  from  the  iris  is  of  a  fibrinous 
nature.  This  is  deposited  first  at  the  pupillary  edge  of  the 
iris,  then  on  its  posterior  surface,  and  sometimes  also  on  the 
anterior  surface.  It  glues  the  iris  to  the  anterior  capsule  of 
the  crystalline  lens,  and  thus  renders  it  partially  or  totally  im- 
moveable. If  the  disease  goes  on,  a  perfect  membrane  may 
be  formed  in  the  pupillary  space,  into  which  blood-vessels 
may  grow  from  the  adjacent  iris  [occlusion  of  the  pupil).      By 


DISEASES  OF  THE  IRIS.  145 

the  formation  of  such  a  pupillary  membrane  or  of  a  circular 
synechia,  or  by  both  together,  the  anterior  chamber  may  be 
shut  off  from  the  parts  of  the  eyeball  lying  behind  the  iris, 
and  thus  the  slow  current  of  the  fluids  within  the  eyeball, 
which  goes  from  behind  forwards,  is  seriously  obstructed  (seclu- 
sion of  the  pupil).     (See  Fig.  52).     This  causes  an  increase  of 


Fig.  52. — Newly  formed  connected  tissue,  the  result  of  a  fibrino-plastic  iritis,  unites 
the  posterior  surface  of  the  iris  with  the  anterior  lens  capsule. 

tension  in  the  posterior  parts  of  the  eyeball  and  the  periphery 
of  the  iris,  if  not  also  glued  down  to  the  lens,  may  be  pushed 
forward  so  as  almost  to  touch  the  cornea  (crater-shaped  pupil). 
That  such  a  condition  cannot  exist  long  without  seriously  en- 
dangering the  function  of  the  eye,  is  obvious.  Most  frequent- 
by  the  inflammation  spreads  backwards  upon  the  ciliary  body 
and  choroid  and  leads  to  perfect  destruction  of  the  eyeball  by  a 
chronic  iridochoroditis.  In  other  cases  the  eye  is  destroyed 
by  secondary  glaucoma.  In  these  stages  of  the  disease  the 
formation  of  the  cataract  is  a  frequent  complication. 

Luckily  the  inflammation  may  sometimes  spontaneously 
come  to  an  end  before  the  more  serious  consequences  are  de- 
veloped. 

From  the  foregoing  it  may  be  seen  that  is  of  the  greatest 
importance  to  recognize  the  disease  early. 

It  may,  therefore,  be  well  to  enumerate  again  the  symptoms 
of  iritis,  as  contrasted  with  those  of  conjunctivitis.  In  con- 
junctivitis the  hyperaimia  of  the  blood-vessels  is  confined  to 


146 


OPHTHALMOLOG  V. 


the  mucous  membrane  of  the  eyeball  and   eyelids.    (See  Fig. 
53).  In  iritis,  although  there  may,  too,  be  a  considerable  hyper- 


FiG.  53. — (After  Dalrymple).     Hyperaemia  of  the  conjunctival  bloodvessels  in  con- 
junctivitis. 

semia  of  the  conjunctival  vessels,  there  is,  in  addition,  hyper- 
aemia  of  the   episcleral  (ciliary)   bloodvessels    (See    Fig.  54), 


Fig.  54. — (After  Dalrymple).  Hyperaemia  of  the  conjunctival  blood-vessels  and  of 
the  episcleral  and  ciliary  blood-vessels  around  the  periphery  of  the  cor- 
nea in  iritis. 


which  shows  as  a  bluish-red  zone  around  the  corneo-scleral 
margin,  over  which  the  hyperaemic  conjunctiva  can  be  moved. 
In  conjunctivitis  the  appearance  of  the  iris  is  unchanged,  and 
the  pupil  dilates  promptly  when  the  eye  is  shaded,  except 
when  the  iris  is  hypersemic;  in  iritis  the  appearance  of  the  iris 
is  materially  altered,  and  it  is  inactive.  In  conjunctivitis,  if 
there  is  pain,  it  is  usually  located  in  the  eyelids;  in  iritis  there 
is  nearly  always  pain,  and  it  usually  irradiates  into  the  regions 
surrounding  the  orbit.  In  conjunctivitis,  vision  is  only  mo- 
mentarily impaired  (by  mucus  lying  on  the  cornea,  which  can 
be  wiped  off  with  the  eyelid);  in  iritis  sight  is  considerably, 
often  very  greatly,  impaired.  Finally,  in  conjunctivitis  there  is 
mucoid  or  muco-purulent  discharge;  in  iritis  there  is  no  dis- 
charge, except  of  tears. 


DISEASES  OF  THE  IRIS.  147 

If  an  iritis  has  been  mistaken  for  a  conjunctivitis,  the  symp- 
toms will  remain  unchanged,  or,  more  probably,  become 
worse,  so  long  as  the  patient  is  treated  for  conjunctivitis;  if  the 
wrong  treatment  is  persisted  in,  permanent  injury  to  the  eye, 
or  even  loss  of  vision  may  be  the  result. 

Plastic  iritis  is  mostly  an  acute  disease,  and  may  in  some 
cases  get  well  without  proper  treatment;  but  very  seldom,  with- 
out leaving  its  traces  behind  in  the  shape  of  a  posterior 
synechia. 

In  some  cases  of  plastic  iritis  due  to  trauma  or  syphilis, 
which  are  characterized  by  haemorrhages  into  the  tissue  proper 
of  the  iris  and  even  the  anterior  chamber  and  between  the 
lamellae  of  the  cornea,  a  special  form  of  exudation  is  found  in 
the  anterior  chamber,  which  is  termed  spongy  exudation  {Gunn^ 
Gruening ). 

This  exudation  formed  probably  by  the  blood-plasma  lookp 
like  dim  gelatine,  and  is  often  only  recognized  after  having 
been  partially  dissolved  and  absorbed.  It  may  then  ap- 
pear as  a  grayish,  lens-like  body,  lying  in  the  anterior 
chamber  like  a  dislocated  crystalline  lens,  but  leaving  its  up- 
permost portion  free.  Gradually  the  whole  of  this  exudation 
is  dissolved  and  absorbed.  This  may  be  accomplished  within 
a  week,  but  it  sometimes  takes  two  or  three  weeks. 

The  average  duration  of  a  plastic  iritis,  even  under  treat- 
ment, varies  from  three  to  six  weeks.  Cases  that  come  under 
treatment  at  the  very  beginning  may,  however,  recover  much 
more  rapidly. 

§75.  Serous  iritis  is  that  form  of  iritis  in  which  the  exuda- 
tion is  considered  to  be  chiefly  of  a  serous  nature.  Besides 
the  general  symptoms  of  iritis,  which  are,  for  the  most  part, 
mild  and  not  clearly  defined,  we  find  usually  a  slight  increase  of 
tension  due  to  the  spreading  of  the  disease  to  the  posterior 
parts  of  the  uveal  tract.  The  synechiae  formed  in  serous  iritis 
are  usually  not  very  firm,  nor  is  the  pupil  as  apt  to  be  small, 
as  in  plastic  iritis.  When  the  tension  is  increased  the  pupil  is 
usually  wide.  During  the  progress  of  the  affection,  the  pos- 
terior layers  of  the  cornea  become  involved,  and  the  endothe- 
lial cells  of  the  membrane  of    Descemet  proliferate.       These 


148  OPHTHALMOL  OGY. 

proliferations  form  numerous  small  whitish  or  pigmented  dots 
on  the  posterior  surface  of  the  cornea.  The  dots  appear 
mostly  in  the  lower  part  of  the  cornea,  and  form  a  dimly  de- 
fined triangle  with  its  base  downwards,  and  its  point  upwards 
in  the  region  of  the  pupil.  From  this  peculiar  arrangement  it 
was  formerly  thought  that  the  dots  were  simply  deposits  of 
fibrine  from  the  exudation  in  the  aqueous  humor,  and  it  is 
not  impossible  that  small  fibrinous  deposits  may  in  reality 
be  the  primary  cause  for  the  proliferation  of  the  endothelial 
cells. 

If  the  disease  progresses,  the  synechiae  become  firmer,  and 
the  result  may  be  again  a  circular  synechia  of  the  pupillary 
edge  combined  with  bulging  of  the  periphery  of  the  iris.  (See 
Fig.  55). 


Fig.  55. — Crater-shaped  iris  (exclusion  and  occlusion  of  the  pupil).  The  pupillary 
edge  of  the  iris  and  the  iritic  pupillary  membrane  adhere  to  the  anterior  lens 
capsule.  The  unchecked  exudation  of  aqueous  humor  into  the  posteiior 
chamber  has  pressed  the  periphery  of  the  iris  forward  toward  the  cornea. 

This  form  of  iritis  is  rather  chronic  in  its  course,  and  does 
not  yield  redily  to  treatment,  which  should  be,  in  the  main,  the 
same  as  in  plastic  iritis.  When  the  disease  has  run  its  course 
and  the  media  are  again  clear  we  not  seldom  find  atrophic 
patches  in  the  choroid. 

^j^i.  The  characteristic  feature  of  purulent  iritis  is  that  pus 
cells  fill  the  tissue  of  the  iris  and  are  exuded  into  the  anterior 
chamber.  The  iris  in  this  form  of  inflammation  often  has  a 
yellowish  tint  which  may  appear  in  localized  spots.  The  pus 
in  the  anterior  chamber  may  be  fluid,  or  semi-fluid  when  fibrine 


DISEASES  OF  THE  IRIS.  149 

is  mixed  with  it.  It  sinks  to  the  lowest  part  of  the  anterior 
chamber,  changing  its  place  when  the  head  is  tilted  to  one 
side,  and  forms  what  we  have  already  seen  in  ulceration  or 
abscess  of  the  cornea,  a  hypopyon.  If  the  affection  is  not  a 
part  of  a  general  purulent  inflammation  of  the  eyeball  (pan- 
ophthalmitis), recovery  may  take  place,  but  not  without  leaving 
its  traces  behind.  The  pain  accompanying  this  form  of  iritis 
is  usually  very  severe. 

Anatomically  very  similar,  though  clinically  distinct,  is  the 
fourth  form  of  iritis  the  gummatous  iritis.  In  it  the  infiltration 
with  round  cells  is  more    localized,  and   we  see    small  tumors 


Fig.  56.— Gumma  of  the  left  iris.     The  pupil  is  partially  dilated  by  atropine. 

{gummata)  forming  mostly  near  the  pupillary  edge.  (See  Fig. 
56).  Generally  we  find  only  one,  sometimes  several  such  tu- 
mors. They  gradually  increase  in  size  and  become  yellow. 
At  this  stage  they  may  disappear  again.  Later  on  we  find  in 
their  place  atrophied  iris-tissue  and  posterior  synechiae. 

In  other  cases  the  gumma  seems  to  burst  through  the  iris 
into  the  anterior  chamber  and  may  totally  fill  it.  This  exuda- 
tion must,  however,  not  be  confounded  with  the  spongy  exu- 
dation described  above.  Gradually  the  gummatous  growth  is 
absorbed  and  an  atrophic  portion  of  the  iris  and  a  posterior 
synechia  mark   its  original  seat. 

Gummatous  iritis  generally  occurs  in  but  one  eye,  more  rare- 
ly in  both  at  the  same  time. 

The  bacillus  of  tuberculosis  i^KocK)  is  sometimes  the  cause 
of  a  tubercular  iritis.  The  diagnosis  is  difficult  and  remains  un- 
certain until  the  characteristic  micro-organism  is  demonstrated. 

'The  etiology  of  the  plastic  and  serous  forms  of  iritis  is 
not  always  clear.  However,  in  a  large  percentage  of  the  cases 
syphilis  is  the  primary  cause.     Some  authors  state  this  to   be 


160  OPHTHALMOL  OGY. 

the  case  in  fully  sixty  per  cent.,  and  if  inherited  taints  could 
always  be  traced,  the  proportion  would  probably  be  still  much 
larger.  When  iritis,  as  it  often  does,  is  seen  in  from  four  to 
six  weeks  after  the  primary  sore  of  acquired  syphiUs  has  made 
its  appearance,  and  while  the  characteristic  skin  eruptions  and 
throat  affections  are  present,  the  diagnosis  is,  of  course,  easy. 
In  the  same  manner  a  gummy  tumor  developing  during  iritis 
will  set  our  doubts  at  rest.  Very  frequently,  however,  iritis  is 
one  of  the  later  or  even  latest  affections  in  syphilis,  and  may 
appear  when  no  other  syphilitic  symptom  can  be  detected. 
Rheumatism  and  gout  predispose  to  iritis.  In  quite  a  number 
of  cases,  probably  a  larger  one  than  is  known,  iritis  is  seen  to 
follow  gonorrhoea,  or  to  appear  soon  after  the  local  infection 
has  made  itself  known.  It  is  usually  preceded  by  gonorrhoeal 
rheumatism  of  the  knees  and  other  joints.  Iritis,  also,  some- 
times develops  during  an  acute  infectious  disease  like  typhus 
and  pneumonia. 

Purulent  iritis  is  almost  always  due  to  an  injury  with  subse- 
quent purulent  infection,  and  is  one  of  the  unfortunate  seque- 
lae of  unclean  operations  on  the  eye.  It  may  also  follow  an 
incarceration  of  the  iris  after  an  extraction  of  cataract. 

In  the  treatment  of  iritis  the  main  point  must  always  be  to 
prevent  the  formation  of  posterior  synechise  or  to  rupture  those 
that  have  already  been  formed.  This  is  accomplished  by  the 
forcible  dilatation  of  the  pupil  by  means  of  mydriatic  drugs, 
among  which  the  sulphate  of  atropia  holds  the  first  place.  A 
one  per  cent,  solution  of  this  drug  is  to  be  instilled  into  the 
eye  every  half  hour,  or  even  every  quarter  of  an  hour,  if  nec- 
essary, until  the  pupil  is  well  dilated  (ad  maximum,  if  possible). 
Those  who  are  not  often  called  upon  to  use  atropia,  are,  as  a 
rule,  afraid  to  use  it  strong  enough  and  often  enough,  and  fre- 
quently when  the  pupil  is  nicely  dilated  they  get  frightened, 
lest  it  should  stay  so  or  even  burst  when  going  on  with  the  in- 
stillations. This  is  all  wrong,  and  the  fact  is,  that  only  the 
persistent  use  of  a  strong  solution  (one  per  cent.)  will  accom- 
plish anything.  The  pupil  will  resume  its  normal  coudition 
(if  there  are  no  synechiae)  in  from  one  to  two  weeks  after  the 
last  instillation  has  been  made. 

Most  people  will  bear  such  instillations  for  a  prolonged  period 


DISEASES  OF  THE  IRIS.  151 

without  any  disagreeable  symptoms,  except,  perhaps,  a  dry 
throat.  A  small  number  of  patients,  however,  will  be  found 
to  be  most  sensitive  to  the  use  of  atropia,  and  to  show  signs 
of  poisoning  after  a  comparatively  small  number  of  instilla- 
tions. The  face  becomes  flushed,  the  pulse  becomes  rapid, 
feeble  and  fluttering,  the  patient  is  nauseated,  has  hallucina- 
tions and  sometimes  even  becomes  delirious.  In  such  a  case 
morphine  must  be  given,  the  use  of  atropia  be  discontinued, 
and  extract  of  belladonna  may  be  tried  in  its  stead.  Before, 
however,  changing  the  remedy,  we  should  try  to  prevent  the 
instilled  solution  from  running  down  the  tear-duct,  by  turning 
the  patient's  head  in  the  opposite  direction  and  closing  the 
canaliculi  for  a  few  minutes  after  the  instillation  by  pressing  a 
finger  against  them. 

Some  eyes  grow  more  painful  when  atropine  is  instilled, 
which  is  probably  due  to  an  increase  of  the  intra-ocular 
pressure. 

Sometimes  also  atropia  proves  irritating  to  the  conjunctiva 
and  causes  a  follicular  swelling,  which  may  become  very  disa- 
greeable. In  such  cases  it  may  again  be  well  to  change  the 
remedy.  I  am  inclined  to  think  that  this  form  of  conjupctivi- 
tis  is  due  to  some  infection  rather  than  the  action  of  the  drug 
itself.  I  certainly  have  never  seen  it,  since  I  have  taken  the 
precaution  to  dissolve  the  atropia  in  a  four  per  cent,  solution 
of  boracic  acid. 

The  next  point  to  be  considered  is  the  relief  of  the  often 
almost  maddening  pain,  which  does  not  always  yield  even 
when  we  have  succeeded  in  fully  dilating  the  pupil.  An  old 
and  undoubtedly  good  remedy  for  this  in  many  cases  is  the 
application  of  from  3  to  6  leeches  to  the  temple.  I  have  also 
often  seen  immediate  relief  following  the  use  of  cold  com- 
presses or  even  of  a  small  ice-bag;  in  some  cases  bathing  with 
hot  water  has  been  more  successful  in  abating  the  pain.  These 
remedies  may  be  combined  with  the  internal  exhibition  of  an- 
tipyrine,  antifebfine  or  morphine. 

Where  there  is  the  least  idea  of  a  specific  origin  in  a  case  of 
iritis,  it  will  be  best  to  at  once  give  mercury  in  some  form  or 
other.  Inunctions  rapidly  pushed,  calomel  in  small  and  fre- 
quent doses,  and  protoiodide  of  mercury,  or  corrosive  sublim- 


152  OPHTHALMOLOGY. 

ate  may  be  used.  If  the  syphilitic  infection  has  taken  place 
many  years  before  the  appearance  of  the  iritis,  the  use  of 
iodide  of  potassium  is  very  effective.  Even  in  cases  where  a 
syphilitic  origin  cannot  be  traced,  mercury  has  often  a  very 
beneficial  influence. 

To  insure  a  more  rapid  and  local  effect  repeated  subcon- 
junctival injections  of  a  few  drops  of  a  one  per  mille  solution 
of  bichloride  of  mercury  are  highly  to  be  recommended.  Sub- 
cutaneous injections  of  muriate  of  pilocarpine,  or  the  exhibi- 
tion of  decoctum  Zittmanii  are  sometimes  useful,  and  some 
authors  have  reported  excellent  success  from  the  internal  use 
of  salicylate  of  soda  or  salol,  especially  in  rheumatic  iritis. 
My  experiences  in  this  direction  have  been  very  disappointing. 

The  photophobia,  which  may  become  increased  when  the 
pupil  is  dilated,  calls  for  the  wearing  of  smoked  glasses.  Most 
patients  feel  better  when  staying  in  a  darkened  room  and  even 
in  bed.     The  bowels  should  be  kept  open. 

§77.  Injuries  to  the  iris  are  in  most  cases  complicated  by 
injuries  of  the  cornea  and  sclerotic,  and  often  of  the  crystall- 
ine lens  or  even  of  the  deeper  parts  of  the  eye.  The  condi- 
tions and  the  treatment  necessarily  vary  very  much  in  differ- 
ent cases  and  will,  as  far  as  not  here  referred  to,  be  spoken  of 
in  Chapter  XV. 


Fig.  57 — Iridodialysis.     The  iris  is  torn  from  its  ciliary  insertion  on  the  right  and, 
thus  a  second  pupil  is  formed. 

A  contusion  of  the  eyeball  may  result  in  an  injury  to  the  iris 
without  further  complication.  It  may  cause  one  or  more  ruptures 
of  the  circular  fibres  at  the  pupillary  edge  of  the  iris,  and  the 
formation  of  small  coiobomata.  In  other  cases  it  produces  a 
detachment  of  the  iris  from  its  peripheral  insertion  {iridodialy- 
sis).    (See  Fig.  57).     The    former  injury  is  comparatively  rare 


DISEASES  OF  THE  IRIS  153 

and  is  usually  of  little  importance.  In  the  latter  there  is  at 
first  considerable  haemorrhage  into  the  anterior  chamber,  and 
after  the  blood  is  absorbed  we  find  at  the  seat  of  the  rent,  at 
the  periphery  of  the  iris,  a  new,  abnormal  pupil,  which  varies  in 
size  according  to  the  extent  of  the  detachment.  Through  this 
second  peripheral  pupil  rays  of  light  enter  the  eyeball,  as  well 
as  through  the  normal  pupil,  giving  rise  occasionally  to  some 
confusion  of  vision.  When  the  rent  is  very  large,  so  that  the 
loosened  iris  floats  about  with  the  movements  of  the  eyeball, 
it  may  be  closed  by  forcing  the  iris  to  grow  to  the  corneo- 
scleral tissue.  This  can  be  done  by  drawing  it,  by  means  of 
forceps,  into  and  allowing  it  to  be  held  between  the  lips  of  a 
small  corneo-scleral  section. 

§78.  The  iris  is  sometimes  the  seat  of  new  formations.  They 
are  either  cysts  or  sarcomata. 

The  cysts  are  the  result  of  an  injury  and  may  be  of  a  serous 
nature,  in  which  case  they  may  be  caused  by  the  adhesion  of 
a  fold  of  iris-tissue  to  the  posterior  surface  of  the  cornea.  In 
most  cases,  however,  these  cysts  originate  from  epithelial  cell 
grafts,  which  have  been  forcibly  driven  into  the  anterior  cham- 
ber and  have  grown  on  the  iris-tissue.  Both  kinds  of  cysts 
may  attain  to  a  considerable  size  before  they  come  under  our 
observation.  The  only  remedy  is  their  total  removal  from  the 
eye  by  iridectomy. 

Sarcoma  of  the  iris  may  be  pigmented  or  unpigmented.  The 
diagnosis  is  rather  difficult.  Yet,  when  we  find  a  small  solid 
tumor  in  the  iris,  which  is  steadily  growing,  and  perhaps  causes 
pain  and  increase  of  tension,  the  diagnosis  of  a  sarcomatous 
newformation  will  probably  be  correct.  In  a  very  early  stage 
such  a  tumor  may,  possibly,  be  removed  by  iridectomy  with 
reasonable  hope  of  saving  the  patient's  eye  as  well  as  his  life. 
Later  on  the  eye  must  be  sacrificed  to  save  life. 

§79.  As  functional  disorders  of  the  iris  we  have  to  mention 
mydriasis,  a  condition  in  which  the  sphincter  pupillae  has  lost 
its  contractility  and  the  pupil  remains  in  a  state  of  maximum 
dilatation;  and  miosis,  in  which  the  pupil  is  strongly  con- 
tracted. 


154  OPHTHALMOLOG  Y, 

Mydriasis  (when  not  caused  by  a  drug)  is,  as  a  rule,  only  a 
symptom  of  further  disorders,  and  especially  of  disorders  in 
the  nervous  apparatus,  and  it  may  be  due  to  ptomaine  poison- 
ing. 

Miosis,  if  not  caused  by  the  action  of  a  drug,  is  almost 
always  a  pathognomonic  symptom  of  affections  of  the  spinal 
cord.  In  these  cases  the  contracted  pupil  will  still  further  con- 
tract during  the  act  of  accommodation  and  convergence,  but 
not  upon  the  stimulus  of  light  {Argyll-Robertson  pupil). 

Hippus^  an  alternate  contraction  and  dilatation,  is  a  rare 
symptom  of  some  cerebral  diseases. 


CHAPTER     XL— DISEASES     OF    THE    CILIARY 

BODY. 

The  close  anatomical  relation  which  exists  between  the  three 
parts  of  the  uveal  tract  makes  it  impossible  for  an  inflammation 
to  exist  for  some  time  in  the  ciliary  body  without  involving 
the  iris  or,  later  on,  the  choroid.  The  forms  of  inflammation 
which  are  observed  in  the  ciliary  body  are,  therefore,  also  es- 
sentially the  same  as  those  which  occur  in  the  tissue  of  the 
iris. 

The  symptoms  of  cyclitis  are  mainly  those  of  iritis.  There 
is  hyperaemia  of  the  conjunctival  and  episcleral  (ciliary)  blood- 
vessels, impairment  of  sight,  photophobia,  lachrymation  and 
severe  pain,  either  spontaneous  or  on  the  slightest  pressure  on 
the  ciliary  region.  The  way  in  which"  a  patient  will  rapidly 
withdraw  his  head  upon  such  pressure,  is  almost  characteristic 
of  cyclitis. 

§80.  Plastic  cylitis,  the  most  frequent  form  of  inflammation 
of  the  ciliary  body,  may  be  acute,  but  it  is  usually  a  chronic 
affection.  It  is  characterized  by  the  exudation  of  fibrinous  or 
plastic  material  into  the  posterior  chamber  (see  Chapter  I)  and 
the  anterior  portion  of  the  vitreous  body.  After  some  time 
this  fibrinous  substance  becomes  organized,  connective  tissue 
is  formed,  and  cells  and  bloodvessels  grow  from  the  ciliary 
body  into  this  newly  formed,  cyclitic  membrane.  As  this  mem- 
brane shrinks,  the  crystalline  lens  is  pushed  forwards,  and 
finally  the  posterior  part  of  the  ciliary  body,  with  the  adjacent 
choroid  and  retina,  becomes  detached  from  the  sclerotic.  Dur- 
ing this  process  the  iris  and  the  crystalline  lens  become  glued 
together,  and  the  eyeball  is  destroyed  by  shrinkage.  (See 
Fig.  58). 

In  serous  cyclitis  the  exudation  is  mainly  serous  in  character. 

This  form  of  cyclitis  is  never  recognized,  without  a  co-exist- 

—155— 


156 


OPHTHALMOLOG  Y. 


ing  serous  iritis.     There  is  increase  of  intra-ocular  tension  and 
all  the  symptoms  of  serous  iritis  are  observed. 


Fig.  58. — The  results  of  fibrino-plastic  cyclitis.  The  crystalline  lens  and  iris  are 
pressed  forward  toward  the  cornea  by  the  shrinking  of  the  cyclitic  mem- 
brane running  across  the  eye  from  ciliary  body  to  cil-ary  b  dy.  On  the 
left,  the  ciliary  body  has  become  detached  from  the  sclerotic.  The  poste- 
rior chamber  is  obliterated. 


Purulent  cyclitis  is  usually  seen  in  cases  of  panophthalmitis. 
It  is  almost  always  due  to  an  injury.  In  some  cases  the  yellow 
pus  exuded  from  the  ciliary  body  may  be  seen  in  the  anterior 
portion  of  the  vitreous,  when  the  other  membranes  of  the  eye- 
ball have  only  yet  begun  to  become  inflamed. 

Gummatous  cyclitis  is  but  seldom  recognized,  although  it 
surely  is  not  of  very  infrequent  occurrence.  It  may  remain  a 
localized  affection  of  the  ciliary  body,  without  doing  further 
dammage;  the  gumma  may  break  outwards  through  the  scler- 
otic, or  it  may  be  absorbed.  Isolated  gummata  have  been 
found  a  number  of  times  in  the  tissue  of  the  ciliary  body. 

The  treatment  of  cyclitis  is  in  no  way  different  from  that  of 
iritis. 

Cyclitis  in  all  its  forms  is  but  rarely  a  genuine  primary  dis- 
ease; it  is  generally  due  to  an  injury  or  to  syphilis.  Exper- 
ience has  shown  that  an  eye  which  has  been  destroyed  by 
cyclitis  due  to  sepsis,  is  a   most    dangerous    companion  to    its 


DISEASES  OF  THE  CI  LIAR  Y  BODY. 


157 


fellow.  Sympathetic  ophthalmia  is  very  frequently  the  result 
of  this  affection.  It  is  therefore  best,  as  a  rule,  to  remove 
such  an  eye  in  time  by  enucleation,  unless  the  patient  is  so 
situated  that  he  can  be  kept  continually  under  observation. 

Newformations  start,  it  seems,  but  rarely  from  the  ciliary 
body.  They  are  sarcomata  and,  chiefly,  me lano- sarcomata, 
(See  Fig.  59). 


Fig   59  — Primary  melanotic  sarcoma  of  the  ciliary  body   begincing  to  invade  the 
iris. 


Injuries  of  the  ciliary  body  are,  as  has  already  been  stated, 
of  a  very  serious  nature.  They  will  be  further  discussed  in 
Chapter  XVIII. 


CHAPTER     XII.— DISEASES     OF     THE     CHOROID. 

The  diseases  of  the  choroid,  except  purulent  choroiditis, 
like  those  of  other  structures  which  make  up  the  posterior 
portion  of  the  eyeball,  can  only  be  correctly  diagnosticated  by 
the  use  of  the  ophthalmoscope.  Without  its  aid  the  old  by- 
word still  holds  good,  that  in  diseases  of  the  back- ground  of 
the  eye,  the  patient  can  see  nothing,  nor  the  physician  either. 

The  chief  symptom  usually  complained  of  in  the  diseases 
of  the  back-ground  of  the  eyeball  is  a  partial  or  total  loss  of 
sight,  sometimes  combined  with  photopsiae. 

The  forms  of  inflammation  which  we  meet  with  in  the  cho- 
roidal tissue,  correspond  very  much  with  those  found  in  the 
iris  and  ciliary  body. 


Fig.  6o.— Plastic  choroiditis.      Histological  appearance  of  a  focus  of  infiltration 
which  spreads  into  the  adjacent  retina. 

§8 1.  Plastic  choroiditis  has  a  number  of  clinical  names, 
which,  however,  are  all  based  upon  varieties  of  one  and  the 
same  pathological  process;  thus  we  speak  of  exudative,  atro- 
phic, disseminate,  syphilitic,  peripheral,  areolar  choroiditis  and 
central  choroido-retinitis. 

In  all  these  forms  we  find  the  exudation  of  fibrino-plastic 
material  into  the  tissue  of  the  choroid  and  the  adjacent  retina. 

—168— 


DISEASES  OF  THE  CHOROID.  159 

This  exudation  is  preceded  by  hyperaemia  of  the  choroid,  and 
is  combined  with  cloudiness  of  the  vitreous  body  and  conges- 
tion of  the  bloodvessels  of  the  optic  papilla  and  retina.  (See 
Fig.  60).  The  cloudiness  of  the  vitreous  body  may  be  diffuse, 
or  separate  smaller  and  larger  flocks  of  fibrinous  substance 
may  be  seen  floating  about  in  it. 

The  fibrino-plastic  material  exuded  into  the  choroid  and  reti- 
na may  be  absorbed  again,  but  in  most  cases  it  becomes  organ- 
ized, and  when  retraction  of  the  newly  formed  connective  tis- 
sue takes  place,  an  atrophic  spot  in  the  retina  and  choroid  re- 
sults, which  is  devoid  of  bloodvessels  and  pigment  and  through 
which  the  whitish  sclerotic  can  be  seen.  The  pigment,  which 
has  been  set  free  by  the  destruction  of  the  pigmented  cells  of 
the  choroidal  tissue,  and  of  the  cells  of  the  pigmentary  epithe- 
lium, is  collected  at  the  periphery  of  the  atrophic  spot  in  such 
a  manner  as  to  give  it  a  darkly  pigmented,  irregular  outline. 
(See  Fig.  61). 


Wi^'f^u: 


Fig.  61. — (After  Foerster).    Ophthalmoscopic  appearance  of  atrophic  patches  in  the 
choroid  (choroiditis  disseminata). 

These  atrophic  spots  are  perceived  by  the  patient  as  blind 
or  dark  spots  {scotomatd)  when  they  lie  near  the  center  of  the 
retina.  While  they  are  being  formed  patients  are  often  an- 
noyed by  light-flashes,  firy  sparks,  etc.  {phoiopsia). 

At  least  one,  in  most  cases  several,  of  these  spots  are  formed 
during  an  attack  of  plastic  choroiditis,  and  frequently  both 
eyes  are  affected  at  the  same  time,  or  one  soon  after  the  other. 

In  the  most  frequent  form  of  plastic  choroiditis,  the  atrophic 


160  OPHTHALMOLOG  V. 

spots  lie,  as  a  rule,  near  the  periphery  of  the  choroid  and  reti- 
na, and  therefore  peripheral  vision  is  chiefly  disturbed. 

In  central  choroido-retinitis  the  exudation  takes  place  in  the 
macula  lutea  (yellow  spot)  itself  or  in  its  immediate  neighbor- 
hood. In  the  beginning  of  this  form  of  choroiditis  central  vis- 
ion is  indistinct,  and  objects  are  seen  distorted  and  often  ap- 
parently smaller  {micropsia)  or  larger  {megalopsia)  than  when 
seen  with  the  healthy  eye  [metamorphopsia),  straight  lines  ap- 
pear bent  or  notched,  etc.  Finally  central  vision  is  entirely 
abolished. 

In  both  these  forms  of  plastic  choroiditis  haemorrhages  into 
the  choroidal  tissue  may  also  occur. 

Plastic  choroiditis  is  very  apt  to  recur,  and  thus  to  render 
vision  more  and  more  defective.  Yet,  from  the  fact  that  it  al- 
ways appears  in  patches,  which  leave  healthy  tissue  between 
them,  it  is  not  apt  to  cause  total  blindness. 

Syphilis,  rheumatism  and  gout  are  often  the  basis  on  which 
such  a  plastic  choroiditis  is  developed.  It  happens  also,  com- 
paratively often,  in  women  at  the  climateric  period.  It  is,  how- 
ever, seen  most  frequently  in  short-sighted  eyes,  and  in  elder- 
ly people,  and  the  short-sightedness  and  age  must  therefore 
predispose  to  such  inflammation. 

With  this  exudative  choroiditis  we  must,  however,  not  con- 
found other  atrophic  changes  in  the  choroid  of  myopic  eyes, 
which  are  evidences  of  and  due  to  the  stretching  of  this  mem- 
branes. They  are  pathognomonic  of  progressive  myopia,  and 
will  be  spoken  of  further  on  in  Chapter  XX. 

Later  on  the  chroiditis  may  help  in  the  production  of  cata- 
ract. 

If  plastic  choroiditis  is  treated  in  its  first  beginning,  espe- 
cially in  syphilitic  cases,  it  may  yield  perfectly  to  treatment. 
This  consists  in  rest  in  a  darkened  room,  local  depletion  and 
the  use  of  iodide  of  potassium  or  of  some  form  of  mercury 
internally  or  by  subconjunctival  injection.  Subcutaneous  in- 
jections of  muriate  of  pilocarpine  are  also  useful.  In  older 
cases  bichloride  of  mercury,  taken  in  small  doses  and  for  a 
prolonged  period,  seems  to  have  a  very  beneficial  action.  In 
some  cases  in  which  the  exudation  into  the  vitreous  body  has 
been  the  predominant  symptom,  and  in  which  other  treatment 


DISEASES  OF  THE  CHOROID.  161 

has  proved  ineffective,  I  have  seen  very  good  results  from  the 
use  of  electricity  in  the  form  of  the  constant  galvanic  current. 
The  eyes  must  be  protected  from  the  irritating  influences  of 
light  by  the  wearing  of  smoked  glasses.  Instillation  of  atro- 
pine is  to  be  recommended,  and  total  rest  of  the  eyes  must 
be  insisted  upon. 

§82.  Serous  choroiditis,  when  not  combined  with  serous  iri- 
tis and  cyclitis,  is  seldom,  if  ever  recognized,  unless  it  causes 
glaucomatous  symptoms  (increase  of  the  intraocular  tension). 
Its  chief  result  is  synchisis  (liquefaction)  of  the  vitreous  body, 
either  wholly  or  in  part.  The  vitreous  body,  which  is  of  a 
jelly-like  consistency  in  the  normal  state,  becomes  in  this  affec- 
tion liquid  like  water.  Serous  choroiditis  may  also  give  rise 
to  detachment  of  the  vitreous  body  from  the  retina,  or  of  the 
retina  from  the  choroid. 

§83.  Purulent  choroiditis  is  characterized  by  the  infiltration 
of  the  choroidal  tissue  and  the  vitreous  body  with  pus-cells.  It 
is  usually  a  very  acute  affection,  and  thus  produces  symptoms 
which  are  plainly  visible  without  the  aid  of  the  ophthalmo- 
scope. The  inflammatory  process  hardly  ever  remains  con- 
fined to  the  uveal  tract,  but  soon  spreads  over  nearly  all  parts 
of  the  eyeball,  and  extends  to  Tenon's  capsule  {panophthalmi- 
tis). It  then  causes  oedema  and  swelling  of  the  eyelids  and 
ocular  conjunctiva  {chemosis),  and  swelling  of  the  orbital  tissue 
with  consequent  exophthalmus.  The  disease,  almost  without 
exception,  leads  to  total  destruction  and  shrinking  of  the  eye- 
ball. 

It,  is,  as  a  rule,  very  painful;  in  some  cases,  however,  the  pain 
is  but  sHght.  In  the  acute  form  the  pus  may  break  through 
the  sclerotic  or  the  cornea,  and  thus  escape.  This  acute  form 
may  pass  over  into  a  chronic  form  in  which  the  inflammatory 
symptoms  are  much  less  severe,  yet  new  exacerbations  will 
recur  and  recur,  and  it  may  be  many  years  before  such  an  eye 
will  be  apparently  quiet.  In  such  eyes  we  find  nearly  always 
occlusion  and  seclusion  of  the  pupil,  a  cyclitic  membrane, 
cataract  and  detachment  of  the  retina  from  shrinkage  of  the 
vitreous  body.     (See  Fig.  62).     Sometimes  the  choroid  is  hy- 


162  OPHTHALMOL  OGY. 

pertrophied  and  of  many  times  its  normal  thickness.  The 
majority  of  its  bloodvessels  is  obliterated.  The  optic  nerve 
is  atrophied  and  the  posterior  parts  of  the  sclerotic  are  con- 
siderably thickened.  During  the  progress  of  this  affection 
deposits  of  lime  and  the  formation  of  bone-tissue  within  the 
choroid  may  take  place.  Gradually  the  eyeball  shrinks  more 
and  more  (chronic  irido-choroiditis,  phthisis  bulbi). 


Fig.  62. — Chronic  iridochoroiditis  after  injury.  There  is  phthisis  anterior  and  the 
whole  eyeball  is  shrunken.  The  sclerotic  is  thicker  than  normal  and 
folded.  The  anterior  and  posterior  chambers  are  filled  with  new-formed 
tissue  and  pressed  forward  together  with  the  cataractous  lens  by  a  shrink- 
ing cyclitic  membrane,  to  which  the  detached  retina  adheres.  The  choroid 
is  changed  to  a  loose  tissue  of  many  times  its  normal  thickness.  The 
dark  portions  within  it  near  the  optic  nerve  are  new-formed  bone. 

Purulent  choroiditis  is  due  to  septic  infection  brought  into 
the  eye  by  an  injury,  or  as  the  result  of  septicaemia  (metastatic 
choroiditis).  Puerperal  septicaemia  is  especially  apt  to  lead 
to  it. 

In  most  cases  it  owes  its  origin  to  an  injury  with  the  subsequent 
presence  of  a  foreign  body  within  the  eyeball.  It  may  lead  to 
sympathetic  ophthalmia  in  the  fellow-eye  and  will,  therefore,  be 
further  spoken  of  again  in  Chapter  XVIII. 

Treatment  is  usually  unavailing  as  regards  the  cure  of  this 
form  of  choroiditis,  and  it  should  therefore  be  simply  addressed 
to  the  relief  of  the  more  important  symptoms.  The  pain, 
which  is  usually  unceasing  and  very  distressing,  may  be  some- 
times alleviated  by  cold  applications,  but,  as  a  rule,  the  pa- 
tients prefer  hot  ones.  The  latter,  furthermore,  hasten  the 
progress  of  the  suppuration,  and  as  the  eye  is  already  doomed, 
this  is  usually  the  best  thing  which  can  be  done.  If  the  che- 
mosis  is  very  pronounced,  so  that  it  prevents  the  eyelids  from 


DISEASES  OF  THE  CHOROID.  163 

closing  over  the  eyeball,  scarifications  of  the  oedematous  con- 
junctiva are  sometimes  indicated. 

If  seen  in  its  early  beginning,  the  trial  should  be  made  to 
combat  the  disease  with  all  antiseptic  measures  at  our  dispo- 
sal, including  the  attempt  to  remove  any  foreign  body  that 
may  be  lodged  in  the  eye.  Intraocular  injections  {Abadie), 
which  have  of  late  been  highly  recommended,  are  still  sub 
judice,  but  may  be  tried.  Of  all  the  antiseptics  used  for  intra- 
ocular injections,  chlorine-water  seems  to  be  the  best  borne 
and  most  effectual. 

Later  on,  when  it  is  evident  that  all  efforts  to  bring  the  dis- 
ease to  a  standstill  are  futile,  the  choice  may  lie  between  evis- 
ceration and  enucleation  of  the  eyeball.  The  question  is  a 
mooted  one,  when  such  an  eye  should  be  enucleated,  and  it 
has  been  stated  that  to  enucleate  during  the  active  stage  is  apt 
to  produce  cerebral  sepsis  and  death.  This  reasoning  seems 
decidedly  faulty.  The  septic  focus  lies  within  the  eye  (except 
in  metastatic  choroiditis),  and  its  removal  under  antiseptic 
precautions  can  prevent  cerebral  sepsis  to  which  such  an  eye 
otherwise  may  give  rise.  It  should,  therefore,  be  removed  as 
soon  as  it  is  evident  that  the  disease  cannot  be  arrested. 

Gummata  undoubtedly  occur  in  the  choroid,  but  they  are 
seldom  recognized  as  such. 

Tubercles  are  sometimes  found  in  the  choroid  during  the  tu- 
berculosis of  the  lungs.  In  rare  cases  the  occurrence  of  tuber- 
cular choroiditis  is  a  primary  affection.  When  the  diagno- 
sis is  primary  tubercular  choroiditis,  the  immediate  removal 
of  the  eyeball  is  indicated. 

§84.  The  malignant  tumors  of  the  eyeball  take  their  origin 
most  frequently  from  the  tissue  of  the  choroid.  These  tumors 
are  sarcomata,  and  are  either  pigmented  or,  in  rare  cases,  un- 
pigmented.  They  may,  furthermore,  contain  newly-formed 
cartilage  or  bone-tissue. 

The  marked  clinical  symptoms  presented  in  its  different 
stages  by  such  a  growth  within  the  eyeball  ought  to  be  known 
to  every  physician.  In  the  first  stage  the  patient  is  gradually 
losing  sight,  although  externally  the  eye  shows  nothing  patho- 
logical, except,  perhaps,  a  few  dilated  bloodvessels  in  the  epis- 


164  OPHTHALMOLOGY, 

cleral  tissue.  In  the  rare  cases  in  which  an  eye  comes  under  ob- 
servation at  this  stage,  it  may  be  possible  to  recognize  the 
tumor  with  the  ophthalmoscope.  The  retina  may  be 
simply  lifted  up  by  it,  or  may  be  detached  at  the  site 
of  the  growth.  In  the  second  stage  the  growing  tumor 
produces  inflammatory  symptoms  which  are  plainly  visi- 
ble without  the  ophthalmoscope.  The  intraocular  ten- 
sion is  increased,  the  crystalline  lens  and  iris  are  pushed 
forwards,  and  the  general  picture  of  glaucoma  (See  Chapter 
XVII)  is  the  result.  There  is  usually  considerable  hyperaemia 
and  pain  during  this  stage.  As  it  may  yet  be  possible  in  the 
glaucomatous  stage  of  the  intraocular  tumor  to  save  the  pa- 
tient's life  by  the  removal  of  the  eyeball,  the  physician  should  be 
well  posted  on  this  symptom.     (See  Fig.  63).      Finally,  in  the 


Fig.  63. — Primary  melanosarcoma  of  the  choroid.    The  retina  is  lifted  up  by  the 
growth. 

third  stage  the  eye  is  totally  blind,  the  iris  and  cataractous 
lens  are  pushed  forwards  against  the  cornea  and  gradually  the 
tumor  breaks  through  the  sclerotic,  or  possibly  the  cornea, 
and  grows  either  into  the  orbital  tissue  or  through  the  anterior 
portion  of  the  eyeball  out  of  the  orbit.  It  may  also  grow 
along  the  course  of  the  optic  nerve.  It  may  fill  the  whole  or- 
bit and  grow  out  of  it  to  a  considerable  size.  Superficial  ul- 
cerations and  haemorrhages  are  then  common. 

During  this  last  stage,  as  a  rule,  metastatic  tumors  have  al- 
ready begun  to  be  formed  in  the  brain,  the  lungs,  the  liver,  or 
some  other  distant  organ  of  vital  importance,  and  the  patient 
is  irrevocably  lost.  It  usually  takes  several  years  to  reach  this 
end. 

There  is  no  treatment  for  such  tumors.      The  only  thing  to 


DISEASES  OF  THE  CHOROID.  165 

be  done  is  to  remove  the  affected  eyeball  at  the  earliest  possi- 
ble period.  Everything  else  is  useless,  and  delay  only  enhan- 
ces the  danger  to  the  patient's  life.  Yet,  as  there  are  but  few 
people  who  are  intelligent  enough  to  submit  at  once  to  the 
inevitable,  the  family  physician  will  generally  be  applied  to  for 
advice,  and  he  will  often  have  the  disagreeable  duty  involving 
on  him  to  indorse  the  statement  of  the  oculist,  and  to  impress 
the  patient  in  the  most  earnest  manner  with  the  danger  of  his 
condition.  The  early  removal  of  such  an  eyeball  often  saves 
the  patient's  life,  and  is  surely  the  only  means  by  which  this 
result  may  be  obtained.  In  some  cases,  however,  relapses  oc- 
cur within  the  orbit,  and  metastases  may  have  been  formed  in 
other  parts,  even  if  the  eye  was  removed  at  so  early  a  period 
that  the  hope  seemed  justified  that  dissemination  had  not  yet 
taken  place. 

§85.  Injuries  to  the  eyeball  by  a  blunt  instrument  which 
does  not  pierce  the  sclerotic  or  rupture  it,  may  lead  to  isolated 
ruptures  of  the  choroid.     (See  Fig.  64).     After  such  an  injury 


Fig.  64. — (After  Knapp).     Isolated  rupture  of  choroid. 

the  fundus  of  the  eye  is  usually  at  first  obscured  by  blood  and 
no  details  can  be  >een.  When  the  blood  is  absorbed,  the  pa- 
tients usually  notice  an  impairment  of  sight,  and  sometimes 
complain  of  metamorphopsia,  just  as  in  a  case  of  central  cho- 
roido-retinitis.  We  find  then,  on  ophthalmoscopic  examina- 
tion, a  rent  in  the  choroid  forming  a  crescent,  generally   con- 


166  OPHTHALMOLOGY. 

centric  with  the  optic  disk  and  near  it,  through  which  the  scle- 
rotic is  seen.  The  edges  of  the  rent  are  pigmented  and  the 
untorn  bloodvessels  of  the  retina  run  across  it. 

Hcemorrhages  are    but  seldom  seen  in  the  choroidal   tissue, 
except  after  injuries  and  during  some  forms  of  choroiditis. 


CHAPTER    XIIL— DISEASES    OF   THE  RETINA. 

§86.  Hypercemia  of  the  retinal  bloodvessels  is  but  seldom 
seen  without  being  caused  by  some  other  eye  affection.  It  is 
always  combined  with  hyperaemia  of  the  optic  papilla.  When 
retinal  hyperaemia  is  the  primary  affection,  it  may  produce  no 
pathological  changes  in  the  structure  of  the  retina;  it  may, 
however,  produce  haemorrhages.  It  is  usually  caused  by  over- 
work, especially  in  bad  light.  Rest,  and  the  moderate  exclu- 
sion of  light  will  generally  suffice  to  do  away  with  its  symptoms, 
which  consist  chiefly  in  the  weakness  of  sight.  Quite  often  an 
error  of  refraction  is  the  predisposing  cause,  and  its  correc- 
tion by  glasses  will  be  followed  by  a  return  to  the  normal 
condition. 

§87.  AncBmia  or  ischcemia  of  the  retinal  bloodvessels,  with- 
out accompanying  pathological  changes  in  the  tissue  of  the 
retina,  is  sometimes  seen  as  a  sequel  of  a  severe,  prostrating 
illness,  especially  when  the  heart's  action  is  considerably  en- 
feebled. Such  an  ischaemia  of  the  retina  causes  partial  or  to- 
tal blindness,  which  may  be  momentarily  relieved  by  puncture 
of  the  anterior  chamber;  the  weakened  heart  may  then  suffice 
to  overcome  the  reduced  intraocular  pressure,  and  to  force  the 
blood  again  into  the  small  retinal  bloodvessels. 

A  similar  condition,  but  due  to  a  contraction  of  the  blood- 
vessel walls,  may  be  caused  by  large  doses  of  quinine.  I  have 
once  seen  it  occur  after  a  very  severe  fright.  In  this  case  the 
normal  condition  was  restored  after  a  very  few  days.  The 
amblyopia,  caused  by  anaemia  dependent  on  prostrating  dis- 
ease, usually  disappears  as  the  patient  recovers  strength  and 
health. 

A  partial  or  total  anaemia  of  the  bloodvessels  of  the  retina, 
with  subsequent  anatomical  changes  in  the  retinal  tissue,  is, 
furthermore,  observed  in  consequence  of  embolism  of  the  cen- 
tral retinal  artery  or  of  one  of  its    retinal   branches,  or  in  con- 

—167— 


168 


OPHTHALMOLOG  V. 


sequence  of  thrombosis  of  the  central  retinal  vein.      (See  Fig. 

65). 

In  embolism  of  the  central  retinal  artery  the  partial  or  total 
blindness  occurs  suddenly  and  the  ophthalmoscope  reveals  a 
perfect  anaemia  of  the  retinal  arteries;  the  retinal  veins  are  at- 
tenuated, but  contain  here  and  there  broken  colums  of  blood. 
Near  the  optic  papilla  and  around  the  macula  lutea,  the  retina 
appears  obscured  by  a  whitish  infiltration,  and  the  fovea  cen- 
tralis is  seen  as  a  small  cherry-red  spot.  This  pronounced  color 
may  be  due  to  a  haemorrhage  behind  the  fovea  centralis,  but 
is  probably  always  due  to  contrast.  After  some  time  the  infil- 
tration in  the  retinal  tissue  disappears,  and  later  on  the  retina 
and  optic  nerve  become  atrophic. 


Fig.  65. — (After  Michel).    Thrombosis  of  the  central  retinal  vein,  six  millimeters 
behind  the  entrance  of  the  optic  nerve. 

In  embolism  of  a  single  branch  of  the  central  retinal  artery 
these  symptoms  and  the  loss  of  function  are  confined  to  the 
part  of  the  retina  which  the  affected  branch  supplies. 

Embolism  of  the  central  retinal  artery  is  usually  due  to  some 
valvular  disease  of  the  heart.  When  seen  early  it  may  in  ex- 
ceptional cases  be  relieved  by  gentle  massage  or  puncture  of 
the  cornea.  By  these  means  the  embolus  may  become  de- 
tached and  be  driven  into  a  smaller  and  less  important  branch. 

Septic  embolism  will  cause  purulent  inflammation  of  the  ret- 
ina and  other  structures  of  the  eye. 

In  thrombosis  of  the  central  retinal  vein  the  arteries  appear 
also  very  thin,  but  the  veins  are  usually  greatly  enlarged,  and 


DISEASES  OF  THE  RETINA.  169 

a  number  of  haemorrhages  are  seen  in  the  retinal  tissue.  It 
may  also  affect  but  one  branch  of  the  central  vein.  It  is 
due  to  heart  disease  and  senile  changes  in  the  walls  of  the 
bloodvessels. 

When  facial  erysipelas  causes  blindness,  as  it  sometimes 
does,  it  may  be  due  to  thrombosis  of  the  central  vein  pro- 
duced by  the  inflammation  and  swelling  of  the  orbital  tissue 
{Knapp). 

%^Z.  Another  form  of  more  or  less  sudden  blindness  owes 
its  origin  to  the  detachment  of  the  retina  from  the  choroid. 
This  is  due  either  to  an  effusion  of  a  serous  fluid  between  the 
two  membranes,  (and  in  this  manner  it  is  most  apt  to  occur  in 
eyes  suffering  from  a  high  degree  of  myopia),  or  it  follows  the 
shrinkage  of  the  vitreous  body  from  some  cause  or  other 
(loss  during  an  operation  or  injury,  fibrinous  degeneration). 
(See  Fig.  66). 


Fig.  66. — Detached  retina  (after  von  Wecker  and  Jseger.) 

Patients  attacked  by  detachment  of  the  retina  usually  state 
that  at  first  a  cloud  seemed  gradually  to  spread  over  the  sight 
until  it  allowed  them  to  see  only  a  part  of  the  object  looked 
at,  and  this  only  as  if  through  a  mist;  at  a  later  stage  sight  is 
reduced  to  virtually  nothing.  It  may  have  taken  a  few  hours, 
or  days,  or  even  months,  to  develop  all  these  symptoms. 

When  a  large  portion  of  the  retina  is  detached,  and  espe- 
cially when  the  detachment  involves  the  peripheric  parts  of 
the  retina,  the  detached  bladder-like  membrane  may  sometimes 


170  OPHTHALMOL  OGY. 

be  seen  with  the  naked  eye  floating  behind  the  crystalline 
lens. 

By  the  examination  of  the  field  of  vision  the  extent  of  the 
detachment  may  readily  be  judged;  examination  with  the  oph- 
thalmoscope will  enable  us  to  make  the  diagnosis  sure. 

Sometimes  we  see  small  rents  in  the  detached  parts  of  the 
retina,  caused  evidently  by  the  pressure  of  the  fluid  exuded 
behind  it.  According  to  Leber  and  Nordenson  these  rents 
precede  the  detachment  and  are  due  to  the  pulling  of  a  shrink- 
ing vitreous  body. 

The  vitreous  body  in  the  myopic  form  of  detachment  of  the 
retina  is  usually  liquified.  The  intraocular  tension  of  the  eye- 
ball is  less  than  normal.     (See  Fig.  6^), 


Fig.  67. — Total  detachment  of  the  retina,     f 

The  diagnosis  is,  as  a  rule,  easily  made.  The  only  affection 
with  which  detachment  of  the  retina  might  easily  be  confound- 
ed is  sarcoma  of  the  choroid,  in  which,  moreover,  retinal  de- 
tachment is  often  actually  present  as  a  complication. 

The  prognosis  is  unfavorable.  Although  we  may  sometimes 
succeed  in  perfectly  curing  a  recent  detachment  of  the  retina, 
relapses  are  almost  sure  to  occur,  and  getting  less  and  less 
tractable,  they  finally  leave  the  eye  in  a  useless  condition. 

The  treatment  now  most  practiced,  consists  in  repeated  hy- 
podermic injections  of  a  solution  of  the  muriate  of  pilocarpine, 
and  the  results,  especially  in  recent  cases,  are  often  for  the 
time  very  satisfactory,  and  may  remain  so  permanently.  This 
method  of  treatment  requires  less  time  and  is  less  disagree- 
able to  the  patient  than  others. 

Among  these,  the  most  prominent  one  is  prolonged  en- 
forced rest  of  the  patient  and  of  the  eyes. 


DISEASES  OF  THE  RETINA.  171 

This  is  accomplished  by  keeping  the  patient  in  bed,  and 
even  as  much  as  possible  on  his  back,  by  paralyzing  his  ac- 
commodation with  sulphate  of  atropia,  and  by  slight,  contin- 
ued pressure  with  a  compressive  bandage.  To  withhold  fluid, 
as  much  as  possible  from  the  patient,  and  even  to  give  him  a 
free  allowance  of  salt  with  every  meal,  is  helpful. 

The  operative  treatment  of  detachment  of  the  retina 
consists  in  puncturing  the  sclerotic  and  choroid  behind  the 
detached  retina,  or  to  pierce  with  the  needle  through  the 
sclerotic,  choroid  and  retina  into  the  vitreous  body.  In  this 
manner  the  exuded  fluid  may  be  withdrawn  from  the  eye 
and  even  an  adhesive  inflammation  be  set  up  at  the  site  of  the 
puncture,  by  which  the  retina  may  be  held  in  place.  Of 
late,  iridectomy  has  been  recommended,  but  it  does  not  seem 
a  rational  procedure.  The  results  of  these  operative  meas- 
ures are  as    insecure   as  those  of  other  forms    of  treatment. 

Later  on,  the  intraocular  tension  of  an  eye  suffering  from 
detached  retina  is  considerably  below  par,  and  the  lens  be- 
comes cataractous,  and  often  a  low- grade  iritis  is  observed. 

Detachment  of  the  retina  usually  attacks  but  one  eye  at  a 
time,  and  but  very  seldom  is  seen  to  befall  the  fellow  eye  at  a 
later  period. 

§89.  Pigmentation  of  the  retina  may,  as  has  been  stated,  be' 
the  consequence  of  plastic  choroiditis,  and  it  then,  as  a  rule, 
remains  stationary.  There  is,  however,  also  a  progressive  form 
of  pigmentation  of  the  retina,  due  to  proliferation  of  the  pig- 
ment epithelium  which  is  called  retinitis  pigmentosa  (^pigmen- 
tary retinitis).  (See  Fig.  68).  This  affection  gradually  leads 
to  atrophy  of  the  retina  through  solidification  of  the  blood- 
vessels by  an  inflammatory  process  in  their  lymph-sheaths  and 
walls,  and  atrophy  of  the  optic  nerve.  It  terminates  usually 
in  blindness.  It  takes,  however,  a  great  many  years  before 
this  final  result  is  reached.  As  the  disease  begins  at  the  pe- 
riphery of  the  retina,  and  only  gradually  advances  towards  its 
center,  peripheric  vision  is  first  destroyed.  Thus  the  visual 
field  becomes  gradually  narrower  and  narrower,  the  patients 
see  as  if  looking  through  a  tube,  until  finally  their  central 
vision  is  also  lost. 


172  OPHTHALMOLOGY. 

A  very  characteristic  symptom  in  this  affection  is  that  the 
patients  see  much  less  distinctly  in  the  dark.  This  condition 
is  known  as  hemeralopsia  or  night-blindness. 


Fig.  68. — (After  Liebreich).      Ophthalmoscopic  appearance  of  the  retina  in  retinitis 
pigmentosa. 

Pigmentary  retinitis  is  always  observed  in  both  eyes.  Treat- 
ment is  but  rarely  useful,  although  in  its  beginning  the  dis- 
ease may  sometimes  be  brought  to  a  standstill,  and  in  older 
cases  vision  may  sometimes  be  improved.  Subcutaneous  in- 
jections of  strychnia,  the  constant  current  and,  when  there  is  a 
history  of  inherited  syphilis,  bichloride  of  mercury  or  some 
other  mercurial  should  be  tried. 

With  regard  to  its  etiology,  consanguinity  of  the  parents 
has  been  thought  by  some  writers  to  be  the  primary  cause. 
Inherited  syphilis  may  also  be  one  of  the  causes. 

The  retinal  tissue  is  not  very  apt  to  become  primarily  in- 
flamed, and  there  are  only  two  distinct  forms  of  retinitis,  not 
dependent  on  choroiditis,  namely,  syphihtic  retinitis  and  albu- 
minuric retinitis,  the  latter  being  actually  a  neuro-retinitis. 

§90.  Syphilitic  retinitis  is  usually  one  of  the  later  manifes- 
tations of   syphilis.      The    ophthalmoscope    shows  the    retina 


DISEASES  OF  THE  RETINA.  173 

dull  and  hazy,  particularly  in  the  vicinity  of  the  optic  papilla 
and  along  the  course  of  the  larger  retinal  bloodvessels.  The 
bloodvessels  themselves  appear  veiled,  and  sometimes  perfect- 
ly covered  in  a  part  of  their  course  by  the  exudation.  The 
retinal  veins  are  broad  and  somewhat  tortuous.  The  optic  pa- 
pilla usually  appears  reddish  and  slightly  swollen,  and  its  out- 
lines are  not  quite  distinct.  If  the  disease  goes  on,  it  leads  to 
hypertrophy  of  the  connective  tissue  of  the  retina,  and  conse- 
quent atrophy  of  its  nervous  elements.  There  is  generally  a 
dust-like  exudation  in  the  vitreous  body. 

The  patients  complain  of  seeing  strange  photopsiae,  dazzling 
lights,  etc.  Their  sight  is  obscured  in  such  a  way  that  they 
need  more  light  than  formerly,  in  order  to  see  distinctly.  The 
degree  of  impairment  of  vision  is,  however,  often  much  less 
than  would  be  expected  from  the  condition  of  the  retina. 

Syphilitic  retinitis  is  very  prone  to  relapse,  and  if  not  prop- 
erly treated,  it  may  as  already  indicated,  lead  to  blindness. 

The  treatment  consists  in  vigorous  anti-syphilitic  measures, 
combined  with  perfect  rest  of  the  eyes  in  a  dark  room,  as- 
sisted by  the  instijlation  of  sulphate  of  atropia,  and  by  local 
depletions. 

§91.  Albuminuric  retinitis  as  its  name  indicates,  is  chiefly 
due  to  albuminuria  /".  e.  to  nephritis  in  all  its  forms,  but  espe- 
cially to  the  shrinking  kidney. 

In  an  eye  suffering  from  albuminuric  retinitis  we  find  the  op- 
tic papilla  swollen  and  infiltrated,  its  normal  outlines  indis- 
tinct or  even  perfectly  hidden  by  a  whitish  exudation,  which 
extends  into  the  neighboring  retinal  tissue.  The  retinal  veins 
are  gorged  with  blood,  and  very  tortuous,  almost  like  cork- 
screws, their  origin  in  the  papilla  is  invisible,  and  parts  of  them 
within  the  retina  are  perfectly  covered  by  a  dense  whitish 
exudation.  The  retina  shows,  moreover,  a  number  of  whitish, 
shining  spots  of  various  shapes.  These  appear,  especially, 
around  the  macula  lutea,  and  are  usually  arranged  in  a  radial 
direction  around  it,  thus  forming  a  very  characteristic  stellate 
picture.  (See  Fig.  69).  Here  and  there  haemorrhages  are 
visible  in  the  retinal  tissue.     In  rare  cases  detachment    of  the 


174 


OPHTHALMOL  OGY. 


retina  around  the  optic  papilla  has  been  observed.  Albumin- 
uric retinitis  is  due  to  changes  in  the  bloodvessels  of  the  reti- 
na, and  belongs  to  the  uraemic  stage  of  nephritis.  Yet,  in 
some  cases,  the  ophthalmoscopic  diagnosis  may  reveal  nephri- 
tis, when  its  existence  has  not  yet  been  thought  of,  because  of 
the  absence  of  other  marked  symptoms  of  the  disease. 


Fig.  69. — Ophthalmoscopic  appearance  ot  neuro-retinitis  albuminurica. 

The  disturbance  of  vision  is  often  strangely  small,  in  view 
of  the  very  conspicuous  changes  in  the  structure  of  the  retina; 
on  the  other  hand  patients  in  later  stages  of  the  disease  may 
sometimes  be  blind  for  hours  at  a  time  and  then  regain  sight, 
without  any  visible  changes  in  the  condition  of  the  retinal  tis- 
sue. This  happens  during  the  so-called  uraemic  attacks  (urcemic 
amaurosis). 

It  is  hardly  necessary  to  say  that,  as  there  is  no  cure  for  a 
well  established  nephritis,  there  is  also  none  for  the  albumin- 
uric retinitis.  The  patients  die  generally  within  one,  or  at 
most,  two  years  after  the  retinitis  has  been  first  observed. 

Similar  forms  of  retinitis  are  sometimes  seen  in  cases  of  in- 
tra-cranial  tumors  with  subsequent  neuro-retinitis.  (See  Chap- 
ter XXII). 


DISEASES  OF  THE  RETINA.  175 

§92.  Hcemorrhages  into  the  retinal  tissue  may  be  observed 
without  being  preceded  by  any  inflammatory  changes,  and  they 
may  come  on  during  inflammatory  diseases  of  the  retina.  The 
retinitis  is  not  due  to  the  haemorrhage  and  the  old  name  of 
hcemorrhagic  retinitis,  is  therefore,  a  misnomer.  Their  cause  is 
a  degeneration  of  the  walls  of  the  bloodvessels,  or  an  embol- 
ism or  a  thrombosis.  They  vary  in  size,  shape  and  number, 
may  attack  one  eye  alone,  or  both  eyes  at  the  same  time,  and 
accordingly  they  interfere  with  vision  to  a  greatly  varying  de- 
gree. In  some  cases  the  retinal  haemorrhages  are  so  numerous 
that  sight  is  nearly  abolished  from  the  start. 

The  exuded  blood  soon  undergoes  fatty  degeneration,  and 
becomes  absorbed,  leaving  an  atrophic  spot  or  spots,  where 
the  nervous  elements  of  the  retina  have  been  destroyed. 
Sometimes,  however,  the  absorption  takes  place,  leaving  no 
trace  behind.  In  other  cases  a  glaucomatous  process  may  be 
set  up  leading  to  the  destruction  of  the  eye.  Having  once 
occurred  in  an  eye  such   haemorrhages  are  likely  to  recur. 

The  causes  of  the  retinal  haemorrhages  are  heart  disease, 
atheromatous  degeneration  of  the  walls  of  the  arteries,  malaria, 
pernicious  anaemia,  etc.,  or,  in  females,  they  may  be  due  to  the 
suppression  of  the  menstrual  flow,  especially  at  the  period  of 
the  change  of  life,  and  to  thrombosis  of  the  central  retinal 
vein,  or  one  of  its  branches. 

The  treatment  of  retinal  haemorrhages  must  adapt  itself  in 
the  main  to  the  particular  causes  which  are  recognized  in  the 
case  in  hand;  at  the  same  time  it  is  well  to  give  the  eyes  per- 
fect rest,  to  give  mild  cathartics  and  perhaps,  also,  to  apply 
leeches  to  the  temple. 

§93.  The  retina  is  sometimes  the  seat  of  a  form  of  malig- 
nant tumor,  which  has  been  called  glioma.  It  is  only  found 
in  children  and  in  many  cases  soon  after  birth.     (See  Fig.  70). 

The  affection  is  usually  noticed  by  the  parents  through  the 
child's  blindness  in  one  or  possibly  both  eyes,  together  with  a 
characteristic  yellowish- gray  reflection  from  the  back- ground 
of  the  eyeball,  which  has  given  rise  to  the  name  of  amaurotic 
cafs  eye. 

The  tumor  usually  grows  rather   rapidly,  and   although  the 


176  OPHTHALMOL  OGY. 

eye  may,  so  long  as  the  tumor  is  small,  show  no  external  sign 
of  anything  being  wrong  within  it,  the  newformation  will  at  a 
later  period  cause  exactly  the  same  symptoms  which  we  have 
described  as  due  to  the  growth  of  a  choroidal  tumor.  Finally 
the  tumor  bursts  through  the  eyeball  and  shows  itself  extern- 
ally. At  the  same  time  it  has  generally  already  invaded  the 
tissue  of  the  optic  nerve.  It  soon  causes  metastases  in  the 
bones  of  the  skull,  the  brain  and  other  organs.  The  only 
remedy  to  save  the  patient's  life  is  the  earliest  possible  re- 
moval of  the  eyeball.  When  the  disease  has  attacked  both 
eyes  at  the  same  time  the  physician  may  find  himself  in  the 
most  disagreeable  position  of  having  to  insist  upon  the 
speedy  removal  of  both  eyeballs  in  the  hope  of  possibly 
saving  the  child's  life.  However,  in  such  cases  the  parents 
usually  refuse  an  operation  and  prefer  to  let  the  child  die. 


Fig.  70. — Glioma  of  the  retina  at  a  comparatively  early  stage. 

When  the  eye  is  removed  too  late,  and  this,  unfortunately, 
is  nearly  always  the  case,  relapses  will  occur  within  the  orbit, 
leading  rapidly  to  death,  although  usually  with  less  suffer- 
ing to  the  child  than  when  the  eyeball  has  been  allowed  to 
burst  and  to  form  a  huge  and  repulsive  tumor. 

In  some  cases  inflammatory  deposits  in  the  vitreous  body 
have  been  mistaken  for  glioma  {pseudo-glioma). 


CHAPTER    XIV.— DISEASES    OF    THE     OPTIC 

NERVE. 

§94.  Hypercemia  of  the  optic  papilla  is  almost  always  ac- 
companied by  hyperaemia  of  the  retina,  and  occurs  as  a  symp- 
tom accompanying  inflammations  of  the  uveal  tract.  But  we 
sometimes  meet  with  a  genuine  hyperaemia  of  the  optic  nerve 
and  retina  alone,  in  which  case  it  may  be  an  early  stage  of  a 
neuritis,  or  simply  a  passing  pathological  condition,  brought 
about  by  over-work,  especially  in  bad  light.  The  symptoms 
and  the  treatment  are  the  same  as  have  been  described  in  con- 
nection with  hyperaemia  of  the  retina.  When  the  hyperaemia 
is  caused  by  an  uncorrected  error  of  refraction,  this  should  be 
corrected  by  properly  selected  glasses. 

The  same  conditions  which  cause  anaemia  of  the  retina,  pro- 
duce also  ancemia  of  the  optic  papilla.  The  anaemia  may  be 
due  to  an  obstacle  of  the  normal  blood  current  or  to  a  dimin- 
ished blood  supply  from  failure  of  the  action  of  the  heart.  In 
the  latter  case  it  is  chiefly  due  to  excessive  haemorrhages,  to 
weakness  of  the  muscle  of  the  heart  from  other  causes,  to 
anaemia  of  the  brain,  or  to  general  anaemia. 

§95.  Neuritis  optica  appears  in  two  forms:  the  more  frequent 
one,  in  which  the  inflammatory  symptoms  of  the  optic  papilla 
and  its  neighborhood  are  plainly  visible  {papillitis^/),  papillo-re- 
tinitiSy  neuro-retinitis,  neuritis-ascendens),  and  a  second  form  in 
which  the  ophthalmoscope  may  at  first  reveal  hardly  any  signs 
of  inflammation,  but  yet  the  symptoms  are  such  as  can  only 
be  explained  by  the  supposition  that  a  neuritis  is  present 
in  the  part  of  the  nerve  which  lies  behind  the  eyeball  (neuritis 
descendens). 

We  sometimes  find,  preceding  neuritis  ascendens,  an  cedem- 
atous  condition  of  the  optic  papilla.  This,  however,  is  soon 
superseded  by  active  inflammatory  symptoms. 

In  most  cases  the    neuritis  involves   first  the  instertitial  con- 

—177— 


178  OPHTHALMOL  OGY, 

nective  tissue  of  the  optic  nerve,  and  the   nerve-fibres  become 
only  secondarily  affected.     (See  Fig.  71). 


Fig.  71- — Longitudinal  section  through  an   optic   nerve   during  interstitial    optic 
neuritis. 

On  examination  with  the  ophthalmoscope  we  find  in  early 
stages  of  optic  neuritis  a  hyperaemia  of  the  optic  papilla,  com- 
bined with  swelling,  and  indistinctness  of  its  outlines.  The 
retinal  veins  are  enlarged  and  tortuous.  Later  on  the  optic 
papilla  becomes  more  and  more  infiltrated  and  swollen.  Its 
color  is  then  a  whitish-gray,  its  normal  outlines  become  per- 
fectly hidden,  and  small  haemorrhages  may  appear  in  its  tissue. 
The  main  trunks  of  the  retinal  bloodvessels  in  the  optic  pa- 
pilla become  so  covered  by  the  infiltration  that  it  may  be  im- 
possible to  recognize  them.  The  surrounding  retinal  tissue 
appears  hazy,  and  haemorrhages  into  the  retinal  tissue  are  sel- 
dom wanting.     (See  Fig.  72). 

The  more  the  swelling  and  infiltration  of  the  optic  papilla 
increase,  the  more  prominent  are  the  symptoms  of  constric- 
tion of  the  retinal  bloodvessels.  This  fact  has  given  this  con- 
dition the  name  of  "choked  disk."  Later  on  the  retraction  of 
the  newly  formed  connective  tissue  and  consequent  atrophy 
of  the  optic  nerve  and  retina  take  place.  In  these  cases  of 
atrophy  after  neuritis  optica  we  are  often  able  to  diagnosticate 
the  preceding  neuritis  long  after  it  has  occurred  by  the  bluish- 
gray  discoloration  and  irregular  outlines  of  the  optic  papilla, 
and  from  the  remaining  traces  of  haemorrhages. 

If  arrested  in  its  early  stages  the  disease  sometimes  gets 
well  without  impairment  of  vision. 

The  patients  come  generally  under  observation  on  account 


DISEASES  OF  THE  OPTIC  NERVE, 


179 


of  impaired  vision;  still,  the  original  causes  of  the  neuritis 
may  have  forced  them  to  seek  a  physician's  advice  before 
the  appearance  of  any  eye-symptoms.  The  condition  of  the 
optic  nerve  may  then  help  to  diagnosticate  the  primary  dis- 
ease. 


Fig.  72. — Ophthhlmoscopic  appearance  of  the  optic  disk  in  optic  neuritis,  with 
striated  haemorrhages. 


The  commonest  primary  causes  of  this  form  of  optic  neu- 
ritis are  intra-cranial  affections,  and  among  these  especially  tu- 
mors, meningitis,  injuries  to  the  skull,  then  albuminuria,  syphilis, 
lead-poisoning  and  diabetes.  The  disease  most  frequently  at- 
tacks both  eyes. 

The  treatment  of  optic  neuritis,  as  of  retinitis,  is  in  the  main 
that  of  its  primary  cause. 

We  shall  have  further  occasion  to  refer  to  this  subject  in 
Chapter  XXII. 

Neuritis  descendens  is  seen  more  rarely. 

The  affection  causes  a  more  or  less  sudden  total  or  partial 
blindness  of  one  or  both  eyes,  and  with  the  ophthalmoscope 
we  find  at  first,  perhaps,  only  a  somewhat  anaemic  optic  pa- 
pilla.    This  anaemia  is  caused  by  pressure  upon  the  arterial 


180  OPHTHALMOLOG  Y. 

bloodvessels.  The  retinal  veins  appear  fuller  than  normal, 
and  there  may  be  also  a  slight  exudation.  Later  on  the  optic 
papilla  and  retina  may  show  signs  of  active  inflammation. 

The  disease  may  end  in  perfect  recovery  or  it  may  lead  to 
a  partial  atrophy  of  the  optic  nerve  and,  especially,  of  those 
fibres  which  go  to  the  macula  lutea.  In  this  case  peripheral 
vision  may  be  normal,  while  central  vision  is  abolished  {central 
scotoma). 

If  there  is  any  general  cause  to  be  detected,  to  which  the 
disease  of  the  nerve  may  be  due,  treatment  must  be  directed 
to  this  cause.  When  we  are  unable  to  find  such  a  cause,  the 
employment  of  subcutaneous  injections  of  strychnia,  iodide  of 
potassium,  mercury  in  some  form,  leeches,  diaphoretics  and 
diuretics  may  be  beneficial. 


Fig.  73. — Atrophy  of  the  optic  nerve  and  consequent  flat  excavation  of  the  optic 
papilla. 

§96.  A  frequent  affection  of  the  optic  nerve  is  atrophy  with- 
out any  visible  sign  of  inflammation,  although  histologically 
an  interstitial  neuritis  has  been  found  to  be  the  rule  {Uhthoff), 
and  it  is  due  undoubtedly  to  impaired  nutrition  and  conse- 
quent degeneration  of  the  nerve-fibres,  produced  by  the  slow- 
ly increasing  newformation  of  connective-tissue.  The  atro- 
phy may  attack  a  part  only  of  the  optic  nerve  fibres,  or  it  may 
involve  the  whole  nerve. 

The  optic  papilla  in  such  a  case  appears  whitish  or  grayish, 
sometimes  dotted,  in  other  cases  of  a  uniformly  shining  white. 
The  retinal  bloodvessels  are   very  small,  and   their   peripheral 


DISEASES  OF  THE  OPTIC  NER  VE.  181 

ends  and  smaller  branches  are  invisible.  (  Later  on  the  optic 
papilla  appears  slightly  excavated.    (See  Fig.  73). 

There  are  often  central  scotomata,  and  the  color  sense  is 
diminished,  or  color-blindness,  especially  for  red  and  green, 
may  occur.  According  to  the  degree  of  atrophy  is  the  im- 
pairment of  sight;  in  the  highest  grades  it  is  totally  abolished. 

The  disease  usually  affects  both  eyes.  A  similar  condition 
may  come  about  from  any  pressure  upon  and  consequent 
impairment  of  the  nutrition  of  the  optic  nerve,  as  in  cases  of 
fracture  implicating  the  optic  canal  {B6rli?i),  or  through  an  ex- 
ostosis, or  from  exudation  in  cerebral  or  cerebro-spinal  menin- 
gitis. 

The  most  frequent  causes  of  this  form  of  atrophy  of  the  op- 
tic nerve  are  syphilis,  the  abuse  of  tobacco  and  alcoholic 
stimulants,  cerebral  and  spinal  diseases.  When  the  affection 
is  due  to  chronic  nicotine  and  alcohol  poisoning  it  is  usually 
preceded  by  a  marked  capillary  hyperaemia  of  the  optic  pa- 
pilla, the  evidence  of  the  interstitial  inflammatory  process 
mentioned  above.  Among  the  sufferers  from  this  affection  those 
engaged  in  the  trade  of  alcoholic  beverages  are  very  frequent. 

The  atrophy  of  the  optic  nerve  following  the  abuse  of  to- 
bacco or  of  alcohol,  or  of  both  together,  has  a  comparatively 
good  prognosis,  if  the  patient  has  enough  moral  energy  left  to 
abstain  totally  from  the  use  of  these  noxious  substances.  Most 
patients  of  this  kind,  however,  will  resist  the  attempt  to  help 
them;  and  here  the  voice  of  the  family  physician  will  often  be  of 
great  importance  in  aid  of  the  efforts  of  the  specialist.  I  have  of- 
ten heard  the  existence  or  even  the  possibility  of  such  an  affec- 
tion laughed  at,  or  at  least  doubted;  yet,  the  fact  is  so  abso- 
lutely certain,  and  the  disease  so  perfectly  recognizable  and 
recognized,  that  every  physician,  who  by  his  doubts  aids  the 
patient  in  evading  the  necessary  restriction,  commits  a  great 
wrong. 

Besides  enforcing  abstinence  from  the  indulgence  in  the  use 
of  tobacco  in  any  form,  or  alcoholic  beverages,  it  will  be  well 
to  give  aid  to  the  usually  poor  appetite,  to  give  iodide  of  po- 
tassium or  some  other  tonic,  and  to  induce  sleep  by  bromide 
of  potassium  or  hydrate  of  chloral.  In  most  cases,  however, 
strychnia  is  the  best    remedy,  particularly  when  used  in   the 


182  OPHTHALMOLOGY. 

form  of  subcutaneous  injections  and  in  comparatively  large 
doses.  Sometimes  the  use  of  electricity  has  proved  success- 
ful. But  all  these  remedies  are  of  no  use  unless  either  total 
or,  if  this  cannot  be  obtained,  at  least  partial  (especially  with 
reference  to  the  alcoholic  beverages,  as  the  general  condition 
of  some  patients  will  not  allow  of  a  total  withdrawal  of  all 
stimulants)  abstinence  from  the  use  of  the  noxious  substances 
is  insured. 

When  syphilis  is  the  cause  of  atrophy  of  the  optic  nerve 
anti-syphilitic  treatment  must  be  resorted  to. 

In  a  number  of  cases  atrophy  of  the  optic  nerve  is  depend- 
ent on  tabes  dorsalis,  or  on  sclerosis  of  the  spinal  cord  or  me- 
dulla and  is  then  always  associated  with  miosis  and  immobili- 
ty of  the  contracted  pupils,  caused  by  the  loss  of  reflex  action. 
The  pupil,  however,  usually  becomes  still  smaller  when  an 
effort  at  convergence  and  accommodation  is  made  {^Argyll- 
Robertson  pupil). 

It  has  been  already  mentioned  that  in  cases  of  atrophy  col- 
or-blindness may  occur  and  it  must  be  considered  a  grave 
symptom. 

This  acquired  color-blindness  must,  however,  not  be  con- 
founded with  the  not  uncommon  congenital  color-blindness  in 
which  there  is  no  disease,  but  a  lack  of  perception  of  certain 
colors.  The  congenital  color-blindness  is  usually  either  a 
red-green  blindness,  or  a  blue-yellow  blindness.  The  acute- 
ness  of  vision  is  generally  perfect  in  this  affection,  and  the 
color-blindness  is  incurable.    (See  Chapter  XXIV). 

The  terms  ainblyopia  and,  especially,  amaurosis  are  frequently 
used  by  practitioners,  and  seem  to  convey  to  the  patients  a 
most  fearful  idea  of  their  condition.  It  may,  therefore,  be  well 
to  state  that  the  term  amblyopia  means  nothing  but  defective 
sight,  and  is,  especially,  used  to  designate  defective  sight  from 
a  disease  of  the  back -ground  of  the  eyeball,  and  more  espe- 
cially, of  the  optic  nerve.  Amaurosis,  also,  is  not  the  name  of 
a  disease,  but  it  means  simply  blindness  from  some  disease  of 
the  fundus  oculi,  especially  from  an  affection  of  the  optic  nerve. 

The  term  hemianopsia  designates  the  loss  of  half  of  the 
field  of  vision.  It  and  its  causes  will  be  detailed  in  Chapter 
XXII. 


DISEASES  OF  THE  OPTIC  NERVE.  183 

§97.  Injuries  to  the  optic  nerve  are  not  of  frequent  occur- 
rence; they  are  usually  cuts  or  rents  and  tears  by  bullets  or 
other  blunt  objects  thrown  into  the  orbit  by  an  explosion  or  a 
similar  accident.  They  lead  invariably  to  partial  or  total  atro- 
phy of  the  optic  nerve,  according  to  the   extent  of  the  injury. 

§98.  The  tumors  of  the  optic  nerve  are  either  myxomatous^ 
fibro-m.yxomatous,  endotheliomatous  {psammoma)  or  sarcoma- 
tous in  nature.  They  usually  spring  from  the  sheaths  of  the 
optic  nerve,  and  destroy  sight,  by  compressing  the  nerve-tissue. 

Aside  from  the  gradually  increasing  blindness  they  cause 
also  a  gradually  increasing  exophthalmus.  This  protrusion 
of  the  eyeball  is  usually  directed  straight  forward  and,  un- 
less the  tumor  is  very  large,  the  mobility  of  the  eyeball  is, 
perhaps,  impaired  in  a  general  way,  but  not  in  any  es- 
pecial direction.  (See  Fig.  74).  This  is  easily  understood, 
since  the  tumor  originates  within  the  hollow  cone  which  the 
external  ocular  muscles  form  within  the  orbit.  For  the  same 
reason  we  find  by  palpation  that  the  tumor  moves  with  the 
eyeball.  The  ophthalmoscope  reveals  either  optic  neuritis  or 
atrophy  of  the  optic  papilla. 


Fig.  74. — Myxoma  of  the  optic  nerve. 

The  treatment  consists  in  an  early  removal  of  the  tumor. 
Formerly  the  eyeball  was  always  removed  with  the  newforma- 
tion,  but  since  Knapp  first  succeeded  in  removing  a  tumor  of 
the  optic  nerve  without  sacrificing  the  eyeball,  the  operation 
has  been  several  times  successfully  repeated,  and  should  always 
be  attempted. 


CHAPTER    XV.— DISEASES    OF    THE    CRYS- 
TALLINE   LENS. 

The  affections  of  the  crystalline  lens,  for  which  patients  seek 
advice,  are  of  two  kinds,  namely,  the  formation  of  a  cataract, 
or  the  dislocation  of  the  crystalline  lens.  Both  affections  may 
be  either  congenital  or  acquired. 

Cataract  is  the  name  for  every  opacity  or  dimness  of  the 
crystalline  lens,  be  it  partial  or  total. 

§99.  The  congenital  forms  of  cataracty  with  which  we  usu- 
ually  count  those  which  are  observed  soon  after  birth,  are:  zon- 
ular cataract,  polar  cataract  and  total  (soft  or   hard)  cataract. 


Fig.  75. — Two  forms  of  congenital  lamellar  (zonular)  cataract. 

Zonular  (lamellar)  cataract  is  the  name  given  to  a  condition 
in  which  one  or  more  layers  of  the  crystalline  lens,  or  only 
parts  of  one  or  of  several  layers  of  its  substance,  are  opaque. 
(See  Fig.  75).  It  is  usually  stationary,  seldom  progressive,  and 
nearly  always  affects  both  eyes.  It  is  often  connected  with 
rhachitis  or  a  strumous  diathesis;  it  seems  also  to  be  in  some 
cases  connected  with  the  fact  of  consanguinity  of  the  parents. 

The  affection  is  usually  first  noticed  by  the  parents  several 
years  after  birth,  and  especially  when  the  children  begin  to 
play  with  small  objects.  I  have  only  once  seen  a  case  24 
hours  after  birth. 

When  the  pupil  is  well  dilated  in  such  cases,  we  see  behind 
it  a  greyish,  circular,  often  striated,  opacity,  covered  anteriorly 
by  transparent  lens-substance,  and  usually  leaving  the  periph- 
ery of  the  crystalline  lens  clear.     The  opacity   generally   ap- 

—184— 


DISEASES  OF  THE  CRYSTALLINE  LENS,  185 

pears  densest  in  the  center,  and  its  outlines  are  usually  well 
defined.  If  the  outlines  of  the  opacity  are  indistinct,  it  may  be 
a  sign  that  the  cataract  is  of  a  progressive  form.  By  the  use  of 
the  ophthalmoscope  it  becomes  evident  what  parts  of  the  crys- 
talline lens  as  yet  remain  clear  and  available  for  vision  and,  on 
the  other  hand,  we  may  judge  whether  some  part  of  the  lens  is 
in  such  a  condition  that  it  might,  perhaps,  be  used  to  better  ad- 
vantage were  the  pupil  more  favorably  situated.  This  point  is 
of  great  importance  with  regard  to  the  method  of  operating 
which  is  to  be  chosen.  Eyes  affected  with  a  similar  cataract 
are  often  near-sighted,  and  may,  furthermore,  show  other  de- 
fects, like  microcornea,  microphthalmus,  or  coloboma  of  the 
iris,  etc. 

Zonular  cataract  usually  prevents  children  trom  attending 
school,  and  therefore  something  ought  to  be  done  to  help  them 
at  an  early  period.  The  operation  which  is  frequently  per- 
formed, and  which  is  often  quite  successful,  consists  in  making 
a  small  iridectomy  in  front  of  the  clearest  part  of  the  periph- 
eral portion  of  the  crystalline  lens.  An  even  better  visual  result 
maybe  obtained  by  allowing  the  iris  to  remain  entangled  in  the 
corneal  wound  {iridencleisis)  and  this  was  at  one  time  a  legiti- 
mate operation.  By  means  of  it  the  pupil  will  be  dislocated 
towards  the  side  without  the  enlargement  resulting  from  an 
iridectomy,  and  some  of  the  diffuse  light,  which  otherwise 
would  fall  into  the  eye,  will  be  excluded.  Although  the  im- 
mediate effect  may  be  thus  improved,  the  procedure  of  causing 
an  incarceration  of  the  iris  in  the  cornea  is  of  somewhat 
doubtful  advantage,  when  we  consider  the  future  of  such  an 
eyeball.  In  fact  very  serious  consequences  such  as  iridocycli- 
tis, glaucoma,  and  even  sympathetic  ophthalmia  of  the  other 
eye,  have  been  occasionally  observed  as  a  result  of  this  par- 
ticular procedure,  which  has  therefore  been  abandoned.  A  sim- 
ple small  iridectomy  or,  when  it  can  be  safely  accomplished, 
a  simple  iridotomy,  is  therefore  generally  to  be  preferred. 

A  large  proportion  of  the  cases  of  zonular  cataract  receive, 
however,  but  little  benefit  or  even  none  at  all,  from  any  of 
these  operations.  It  is,  therefore,  necessary  in  a  great  number 
of  the  cases  to  get  rid  of  the  whole  lens  by  incising  the  anterior 
lens-capsule  and  thus  allowing  the  lens-substance  to  be  slowly 


186  OPHTHALMOLOG  Y. 

dissolved  by  the  action  of  the  aqueous  humor.  This  little 
operation,  called  discission,  must  generally  be  repeated  several 
times  until  a  clear  pupil  is  obtained.  The  time  thus  consumed 
by  the  rather  slow  process  of  absorption  may  be  considerably 
shortened  by  the  extraction  of  part  or  all  of  the  swollen  lens- 
substance  a  few  days  after  discission. 

An  eye  which  has  been  operated  upon  in  this  manner  is,  of 
course,  deficient  in  refractive  power  and  has  also  entirely  lost 
the  faculty  of  accommodation,  yet  with  the  help  of  proper 
glasses  vision  is  usually  comparatively  good,  and  a  moveable, 
round  and  central  pupil  is  procured  as  in  the  normal  eye.  I 
have  performed  this  operation  quite  a  number  of  times  with 
marked  success  in  eyes  even  which  had  previously  been  oper- 
ated upon  by  iridectomy  with  little  or  no  benefit,  and  I  person- 
ally prefer  it  to  iridectomy  in  almost  every  case. 

Anterior  polar  ox  pyramidal  cataract  consists  in  a  small  dens- 
ly  opaque  cone,  sitting  apparently  upon  the  middle  of  the  an- 
terior surface  of  the  lens-capsule,  but  really  enclosed  within   it. 

What  is  sometimes  called  di  posterior  polar  cataractisususXly 
a  deposit  upon  the  posterior  lens-capsule,  and  is,  therefore, 
properly  speaking,  no  cataract  at  all. 


Fig.  76. — Congenital  anterior  polar  (pyramidal)  cataract  and  coloboma  of  the  iris. 

Anterior  polar  or  pyramidal  cataract  is  sometimes  seen  to  de- 
velop, after  perforation  of  the  cornea  in  childhood,  it  is,  however, 
usually  a  congenital  affection,  and  sometimes  repeats  itself 
in  several  children  of  the  same  family.  When  congenital  it  may 
be  the  only  visible  defect  or  it  may  be  combined  with  other  mal- 
formations (microcornea,  microphthalmus  or  coloboma  of  the 
iris,  or  of  iris  and  choroid,  etc.).  (See  Fig.  76).  If  no  other 
malformation  exists  with  it,  it  is  not  impossible  that  ulceration 
with  perforation  of  the  cornea  and  the  subsequent  adhesion  of 


DISEASES  OF  THE  CRYSTALLINE  LENS.  187 

the  anterior  lens-capsule  to  the  cornea,  during  foetal  life,  have 
been  the  cause  of  the  formation  of  the  opaque  cone.  (6^. 
Becker), 

In  an  eye  affected  with  this  form  of  cataract  the  light  can, 
of  course,  only  enter  peripherally.  We  may,  therefore,  be 
able  to  improve  the  sight  materially  by  an  iridectomy,  or 
we  may  have  to  resort  to  discission  of  the  lens-capsule  in 
order  to  bring  the  absorption  of  the  whole  crystalline  lens  or 
to  extraction  of  the  lens,  just  as  in  lamellar  cataract. 

Total  congenital  cataract  may  be  perfectly  soft,  or  it  may 
have  a  hard  nucleus.  Sometimes  the  whole  cataract  is  thin 
and  shrunken.  In  this  case  it  has  probably  been,  in  the  be- 
ginning, a  soft  cataract,  and  has  lost  some  of  its  more  fluid 
parts  by  exosmosis. 

The  removal  of  a  total  congenital  cataract  should  be  effected 
as  early  as  possible,  and  the  urgency  is  even  greater  than  in 
cases  of  zonular  or  pyramidal  cataract,  inasmuch  as  the  latter 
allows  of  some  sight,  while  in  total  cataract  there  is  no  vision 
of  objects,  but  only  perception  of  light.  The  longer  we  delay 
the  operation,  therefore,  the  less  will  be  the  probability  of  ob- 
taining good  and  useful  vision.  Soft  total  cataract  may  be  re- 
moved by  discission  of  the  anterior  lens-capsule  or  by  simple 
extraction;  harder  ones  had  better  always  be  extracted,  and 
this,  also,  can  mostly  be  done  without  an  iridectomy.  Shrunk- 
en cataracts  may  be  divided  or  may  be  gently  pulled  out  of 
the  eye  through  a  corneal  section  with  forceps  or  a  sharp  hook. 

In  all  three  forms  of  congenital  cataract  nystagmus,  i.  e.,  a 
continued  motion  of  the  eyeballs,  generally  a  pendulum  mo- 
tion, will  develop,  if  the  obstacle  to  distinct  vision  is  not  re- 
moved at  an  early  date. 

§ioo.  More  frequently  than  the  different  forms  of  congenital 
cataract  we  see  those  of  acquired  cataract.  To  designate  the 
different  stages  of  this  process  from  its  beginning  to  its  end, 
we  speak  of  an  incipient,  unripe  (immature),  ripe  (mature) 
or  over-ripe  (Jiypermature)  cataract.  We  call  a  cataract  ripe 
when  the  lens  is  opaque  throughout.  This  is  determined  by 
the  fact  that  under  oblique  illumination  the  shadow  of  the 
pupillary  edge  of  the  iris  is  no  longer  visible  in  the  lens-cortex 


188  OPHTHALMOLOGY. 

and  that  we  can  no  longer  obtain  any  trace  of  a  reflex  from 
the  back-ground  of  the  eye  with  the  ophthalmoscope.  When 
the  cataract  is  ripe  the  patient's  sight  is  usually  reduced  to 
perception  of  light.  In  over-ripe  cataract  we  iind  the  outer  or 
cortical  parts  fluid  or  semi-fluid,  and  we  can  often  see  the  yel- 
lowish nucleus  lying  "at  the  bottom  of  the  lens-capsule,  and 
changing  its  place,  according  to  the  law  of  gravitation.  Such 
patients  may  then  be  able  to  see  objects  to  a  certain  extent. 
Sometimes  the  total  absorption  of  a  cataract  takes  place  and 
a  good  (aphakial)  vision  is  restored. 

With  regard  to  the  consistency  of  the  cataract  we  have  a 
soft  or  even  fluid  cataract,  a  semi-soft  cortical  cataract,  a  hard 
nuclear  cataract. 

The  soft  or  fluid  cataract  is  most  frequently  found  in  young 
people.  It  appears  generally  of  a  milky  white  or  bluish  color 
and  the  fluid  contents  seem  to  bulge  the  anterior  lens-capsule 
forwards.  In  later  stages  deposits  of  lime  or  cholesterine  may 
be  seen  in  it,  or  the  cataract  may  shrink  by  giving  off  some  of 
its  fluid  parts.  The  anterior  lens-capsule,  which  at  an  earlier 
period  appears  tense,  will  then  become  wrinkled,  and  it  may  in 
these  cases,  also,  happen  that,  as  a  result  of  the  shrinkage,  a 
part  of  the  pupil  becomes  uncovered  and  vision  is  more  or  less 
perfectly  re-established. 


Fig.  77.— Cortical  Cataract. 

Cortical  cataract,  the  most  frequent  kind,  consists  in  the 
primary  loss  of  transparency  of  the  cortical  layers  of  the 
crystalline  lens.  (See  Fig.  yj)  The  formation  of  this  form 
of  cataract  usually  begins  at  the  equator  of  the  crystalline 
lens;  and,  in  its  incipient  stages,  it  can  be  diagnosticated 
only  after  full  dilatation  of  the  pupil.  It  is  then  best  seen 
by  means  of  the  ophthalmoscope.  Gradually  the  whole 
cortex   of  the   crystalline    lens    assumes    a   striated    appear- 


DISEASES  OF  THE  CRYSTALLINE  LENS,  189 

ance,  and  the  opalescent  striae  are  arranged  around  a  center 
(the  anterior  pole  of  the  lens)  like  the  spokes  of  a  wheel.  As 
the  disease  advances  these  spokes  become  broader  and  denser 
and  appear  of  a  grayish-white  or  pearl-gray  color.  Finally,  in 
the  stage  of  ripeness,  the  whole  cortex  is  involved,  and  vision 
is  reduced  to  the  perception  of  light.  While  these  changes 
are  going  on  in  the  cortex  of  the  lens,  the  nucleus  generally 
retains  nearly  the  normal  degree  of  transparency  and  hardness 
belonging  to  the  age  of  the  patient. 

Nuclear  or  hard  cataract,  is  the  senile  cataract  proper.  In 
this  form  of  cataract  the  central  hardening  of  the  crystalline 
lens,  which  in  middle  and  advanced  life  results  in  the  forma- 
tion of  the  nucleus,  goes  on  to  the  very  periphery  of  that  or- 
gan. (See  Fig.  78).  Such  a  cataract  is  hard,  and  has  an  am- 
ber tint.  It  does  not,  as  a  rule,  entirely  obscure  sight,  and  it 
often  allows  patients  to  count  fingers  at  some  distance,  even 
when  it  is  perfectly  ripe.  This  kind  of  cataract  develops  slow- 
ly, and  the  striae  in  the  cortical  substance  may  be  but  little 
pronounced. 


Fig.  78.— Nuclear  Cataract. 

When  these  different  forms  of  cataract,  which  usually  ap- 
pear at  a  more  advanced  period  of  life,  are  seen  in  an  other- 
wise apparently  healthy  eye,  they  are  called  uncomplicated 
cataracts.  When  other  affections,  or  their  results,  are  present 
in  a  cataractous  eye,  they  are  called  complicated  cataracts. 
Thus  a  cataract  may  be  complicated  by  corneal  scars,  poster- 
ior synechias,  atrophic  choroiditis,  detachment  of  the  retina, 
glaucoma,  synchisis  of  the  vitreous  body,  atrophy  of  the  optic 
nerve,  etc.  CompHcated  cataracts  are  generally  much  less  fa- 
vorable for  operation  than  the  uncomplicated  ones,  and  the  re- 
sulting vision  is  below  par. 

When  cataract  develops  in  young  individuals  its  formation 
may  be,  and  often  is,  due  to  diabetes  mellitus  {diabetic  cataract) 


190  OPHTHALMOLOG  Y. 

The  development  of  cataract  in  youth  and  in  the  early  years 
of  adult  life  is,  moreover,  often  dependent  on  some  inherited 
tendency,  and  may  show  itself  in  several  members  of  the  same 
family,  like  the  congenital  forms. 

At  a  certain  stage  in  the  development  of  a  cataract,  the 
crystalline  lens  becomes  swollen,  while  still  tolerably  transpar- 
ent; and  in  this  stage  the  eyes  often  become  short-sighted,  so 
that  a  patient  who  has  long  used  glasses  for  reading,  can  read 
again  without  glasses,  and  may  even  see  better  at  a  distance 
with  concave  lenses. 

The  etiology  of  the  formation  of  cataract  is  still  shrouded 
in  mystery.  Nephritis  has  been  claimed  to  be  a  frequent 
cause,  but  careful  examination  showed  this  idea  to  be  falla- 
cious. Of  late  some  observers  insist  on  its  being  due  to  a  low 
degree  of  peripheral  choroiditis,  brought  on  especially  by  un- 
due strain  of  the  eye  consequent  upon  uncorrected  or  badly 
corrected  errors  of  refraction.  0.  Becker  gave  it  as  the  result 
of  his  researches  that  cataract  is  an  inflammatory  disease  of 
the  crystalline  lens,  as  shown  by  proliferation  and  metamor- 
phosis of  the  capsular  epithelial  layer.  If  the  theories  of  the 
inflammatory  character,  be  it  primarily  in  the  choroid  or  in 
the  capsular  epithelial  layer  are  correct,  it  is  to  be  hoped  that 
some  means  of  treatment  may  be  found  by  which  to  stay  the 
process,  and,  indeed,  some  claims  in  this  direction  have  been 
put  forward. 

Unfortunately  in  the  vast  majority  of  the  cases  of  ac- 
quired cataract  the  dimness  progresses  in  spite  of  all 
our  eflbrts,  and  nothing  remains  to  be  done  in  order  to 
restore  vision  but  to  remove  the  opaque  crystalline  lens 
from  the  eyeball,  or  at  least  from  the  axis  of  vision,  by 
means  of  a  surgical  operation.  The  operation  of  discis- 
sion, which  has  been  already  described,  in  connection  with 
congenital  cataract,  is  applicable  also  to  softer  acquired 
cataracts  in  persons  under  30  years  of  age,  or  the  division  of 
the  capsule  may  be  followed,  after  the  lapse  of  a  few  days, 
either  by  the  removal  of  the  soft  and  swollen  lens-substance 
through  a  simple  linear  incision  made  for  this  purpose  in  the 
cornea,  or  by  aspiration  by  means  of  a  tubular  curette.  If  the 
cataract  is  hard  or  has  a  hard  nucleus,  which  is  ordinarily  the 


DISEASES  OF  THE  CRYSTALLINE  LENS,  191 

case  in  persons  who  have  reached  or  passed  the  middle  period 
of  Hfe,  the  operation  known  by  the  name  of  extraction,  and 
which  has  for  its  object  the  removal  of  the  opaque  crys- 
talline lens  from  the  eyeball,  is  alone  applicable.  Extraction 
may  be  performed  in  several  different  ways,  such  as  vary- 
ing the  form  and  position  of  the  corneal  incision,  extract- 
ing the  lens  through  the  normal  pupil,  or  enlarging  the  pupil 
by  an  iridectomy,  opening  the  lens-capsule  and  allowing  it  to 
remain  within  the  eyeball  after  the  extraction  of  the  lens-sub- 
stance, or  extracting  the  cataractous  lens  enclosed  in  and  with 
the  capsule,  etc. 

It  does  not  fall  within  the  scope  of  this  book  to  give  more 
than  a  bare  sketch  of  such  an  operation  as  cataract-extraction, 
and  for  this  the  reader  is  referred  to  Chapter  XXV.  Every 
physician  ought,  however,  to  have  a  definite  idea  as  to 
the  best  time  at  which  to  operate  for  cataract,  and  also  to  know 
something  about  the  prognosis  of  such  an  operation. 

Cataract  extraction  should  not  be  performed  until  the  cata- 
ract is  ripe  (and  that  is  in  most  cases  until  vision  is  reduced 
to  the  bare  faculty  of  differentiating  between  light  and  shade), 
except  in  special  cases  and  when  the  patient  is  over  60  years 
of  age.  The  signs  by  which  the  ripeness  of  a  cataract  is  in- 
dicated have  been  detailed  above.  Unripe  and  over-ripe  cata- 
racts give  often  less  satisfactory  results  after  an  operation  than 
ripe  ones.  Before  advising  an  operation,  the  physician  must  sat- 
isfy himself  that  the  eye  is  in  an  otherwise  healthy  condition.  It 
is,  therefore,  desirable  that  every  physician  should  be  able  to  ex- 
amine the  eye  with  regard  to  its  function  of  vision.  The  patient 
should  be  able  to  see  a  candle-flame  in  an  ordinary  darkened 
room  across  the  whole  room,  and  also  to  point  out  in  what  di- 
rection the  candle  is  held.  If  he  cannot  do  this  the  cataract  is 
usually  in  some  way  a  complicated  one.  If  there  are  no  visible 
signs  of  former  inflammation  of  the  cornea  or  iris,  the  trouble 
must  be  sought  for  further  back.  By  now  examining  the  field  of 
vision  with  a  lighted  candle  in  a  darkened  room,  as  detailed  in 
Chapter  II,  we  first  of  all  confirm  or  correct  the  former  observa- 
tion made  with  the  candle;  and  secondly,  we  examine  whether 
there  may  be,  perhaps,  a  well  defined  portion  of  the  field  of  vision 
wanting,  in  which  case  the  diagnosis  of  an  atrophic  choroiditis 


192  OPHTHALMOL  OGY. 

or  of  a  detachment  of  the  retina  is  to  be  made,  and  the  progno- 
sis is  modified  accordingly.  The  latter  affection  is  the  most 
likely  to  be  present  if  the  eyeball  is  also  soft.  If  the  pupil  di- 
lates but  slowly,  and  then  not  fully  even  after  the  instillation 
of  sulphate  of  atropia,  there  is  probably  something  wrong  in 
the  uveal  tract,  and  such  eyes  are  less  favorable  subjects  for 
extraction  of  the  cataract,  even  when  the  functional  examina- 
tion reveals  no  further  disturbance. 


Fig.  79. — Secondary  (capsular)  cataract  after  extraction  of  lens  by  Graefe*s  method. 

After  cataract  extraction  has  been  performed  by  any  of  the 
methods  in  which  the  lens-capsule  is  left  in  the  eyeball,  this 
membrane  may  give  occasion  for  a  secondary  operation 
through  its  becoming  dim  and  wrinkled,  forming  what  is  called 
a  secondary  cataract.  (See  Fig.  79).  In  such  a  case  the 
tearing  apart  of  the  lens-capsule  (discission)  as  soon  as  may 
be  after  the  primary  operation,  is  sufficient  to  improve  vision 
materially.  The  longer  we  wait,  the  tougher  the  lens-capsule 
will  become,  and  it  may  finally  become  almost  impossible  to 
cut  it.  When  there  has  been  an  iritis,  and  perhaps  an  irido- 
cyclitis after  the  operation,  the  lens-capsule  and  the  newly 
formed  membrane  due  to  the  inflammation,  become  glued  to- 
gether into  one  continuous  membrane.  Iridotomy  (iritomy) 
may  then  be  performed  with  the  result  of  giving  the  patient 
some  useful  sight,  especially  if  the  tension  of  the  eyeball  is 
not  diminished. 

§101.  Injuries  to  the  crystalline  lens  by  which  the  lens- 
capsule  is  cut  or  ruptured  cause  the  formation  of  cataract 
(traumatic  cataract).  When  the  wound  of  the  capsule  is  very 
small  it  may  be  so  quickly  closed  by  proliferation  of  the  cap- 


DISEASES  OF  THE  CRYSTALLINE  LENS.  193 

sular  epithelium,  that  no  appreciable  quantity  of  aqueous  hu- 
mor comes  in  contact  with  the  lens-substance,  or  the  iris  may- 
be driven  into  the  capsular  wound  and  thus  plug  it.  If  this 
happens,  the  dimness  of  the  crystalline  lens  may  remain  con- 
fined to  the  wound  and  its  immediate  neighborhood  and  never 
progress.  These  cases  are,  however,  rare  exceptions.  The 
rule  is  that  the  capsular  wound  admits  of  sufficient  imbibition 
of  the  lens-substance  with  aqueous  humor  to  render  a  large 
portion,  if  not  all,  of  it  dim.  Inflammatory  reaction  of  the 
capsular  epithelium  also  helps  in  the  progress  of  this  form  of 
cataract. 


Fig.  8o.  —Dislocation  of  a  semi-transparent  crystalline  lens  which  is  reduced  in  size 
into  the  anterior  chamber. 

By  a  blow  upon  the  eye  with  a  blunt  instrument  the  crystal- 
line lens  may  be  torn  from  its  suspensory  ligament  (zonule  of 
Zinn),  or  the  latter  may  be  torn  from  the  ciliary  body.  Thus 
the  crystalline  lens  becomes  dislocated.  The  dislocation  may 
take  place  backwards  into  the  vitreous  body  or  forwards  into 
the  anterior  chamber  (See  Fig.  80),  or  the  dislocated  lens  may 
remain  partly  in  the  vitreous  body  and  partly  in  the  anterior 
chamber.  If  the  upper  part  of  the  zonule  of  Zinn  is  torn  to 
a  small  extent  only,  the  crystalline  lens  may   sink  behind  the 


Fig.  82. — Dislocation  of  the  crystalline  lens  into  the  vitreous  chamber  downwards, 
showing  the  characteristic  semilunar  space  of  the  pupil. 

iris  and  a  part  of  the  pupil  be  thus  freed  from  it.      (See  Fig. 
81).     If  after   such  an   injury  the  iris  trembles   (irido  done  sis) 


194  OPHTHALMOLOGY. 

with  the  movements  of  the  eyeball,  the  diagnosis  of  a  disloca- 
tion of  the  crystalline  lens  is  almost  certain.  The  periphery 
of  a  dislocated  lens,  as  far  as  it  lies  in  the  field  of  the  pupil, 
may  be  seen  as  a  black  arc,  when  viewed  by  diffuse  light  or 
with  the  ophthalmoscope,  in  consequence  of  the  total  reflection 
of  the  light;  but  as  a  shining,  yellowish-white  arc,  when  viewed 
under  oblique  illumination.  For  better  demonstration  colored 
light  may  be  thrown  into  the  eye,  when  the  arc  will  appear 
colored  by  it.  When  the  whole  of  the  crystalline  lens  is  dis- 
located into  the  anterior  chamber,  it  may  fill  the  chamber  so 
completely  that  there  may  be  some  difficulty  in  recognizing 
it  until  it  becomes  dim.  It  usually  causes  an  increase  of  the 
intraocular  tension  with  all  its  disagreeable  consequences  and 
by  these  means  the  diagnosis  soon  becomes  easy. 

Dislocation  of  the  crystalline  lens  (generally  downwards) 
may  also  happen  spontaneously  in  consequence  of  synchisis 
of  the  vitreous  body  and  consequent  weakening  of  the  fibres 
of  the  suspensory  ligament.  This  is  the  rule  when  dislocation 
occurs  in  short-sighted  eyes.  Dislocation  of  the  crystalline 
lens  may  be  also  a  congenital  defect,  and  is  known  by  the 
name  of  ectopia  lentis. 

An  eye  with  a  dislocated  lens  is,  as  far  as  the  pupil  is  freed 
from  the  lens,  in  the  same  condition  as  an  eye  which  has  been 
operated  upon  by  the  removal  of  a  cataract.  According  to 
its  former  refraction  it  may  be  emmetropic  or  far-sighted.  The 
part  of  the  pupil  behind  which  the  dislocated  lens  lies  is  usu- 
ally myopic.  An  eye  with  a  dislocated  crystalline  lens  cannot 
accommodate. 

Dislocated  crystalline  lenses,  as  a  rule,  gradually  become 
dim.  Their  position  and  motility  with  the  consequent  mechan- 
ical irritation  may,  furthermore,  lead  to  inflammation  of  the 
iris,  ciliary  body  and  choroid.  A  crystaUine  lens  dislocated 
into  the  anterior  chamber  generally  causes  glaucoma,  as  already 
stated.  A  partially  dislocated  crystalline  lens  need  not  be  in- 
terfered with  until  it  becomes  cataractous  or  at  least  until  its 
presence  causes  further  trouble  in  the  eye,  and  the  extraction 
of  such  lenses  is  usually  quite  difficult.  The  use  of  eserine  or 
any  other  miotic  agent  may,  at  first,  by  the  contraction  of  the 
pupil,  be  very  agreeable  to  the  patient,  but  its  use  cannot  well 


DISEASES  OF  THE  CRYSTALLINE  LENS,  195 

be  kept  up  ad  infinitum^iVid it  has,  of  course,  no  curative  effect. 

A  crystalline  lens  dislocated  totally  into  the  anterior  cham- 
ber should  be  at  once  removed  by  a  peripheral  section,  as  in  an 
ordinary  cataract  extraction. 

The  absence  of  the  crystalline  lens,  whether  as  a  result  of 
dislocation  or  of  an  operation  for  cataract,  is  designated  by 
the  name  of  aphakia. 

The  condition  of  aphakia  brings  with  it  of  necessity  the 
loss  of  the  power  of  accommodation  and  a  change  in  the  re- 
fractive state  of  the  eye.  These  conditions  generally  render 
the  wearing  of  strong  convex  glasses  necessary  for  both  dis- 
tant and  near  vision.  In  cases  of  myopia  only,  when  of  a 
high  degree,  the  removal  of  the  lens  may  render  the  eye  em- 
metropic or  at  least  so  nearly  so  that  such  patients  may  be  able 
to  do  without   glasses  for  distant  vision  with  comfort. 


CHAPTER     XVL— DISEASES    OF     THE     VITREOUS 

BODY. 

§102.  Affections  of  the  vitreous  body  are  always  secondary 
affections  and  are  due  to  the  diseases  of  the  membranes  sur- 
rounding it,  in  most  cases  to  diseases  of  the  choroid  and  ciH- 
ary  body.  We  distinguish  between  a  serous  hyalitis  (synchisis 
corporis  vitrei),  2i  fibrinous  or  plastic  hyalitis,  and  a  purulent  hy- 
alitis. Yet,  it  must  be  thereby  understood,  that  these  forms 
of  inflammation  of  the  vitreous  body  (hyalitis)  are  only  exten- 
sions of  inflammatory  processes  of  a  corresponding  character 
in  the  uveal  tract,  or  in  the  optic  nerve  and  retina.  It  often 
happens,  however,  that  the  changes  in  the  vitreous  body  due 
to  the  hyalitis,  continue  long  after  the  primary  affection  has 
run  its  course,  or  may  even  remain  permanent. 

We  find  this  to  be  the  case  especially  with  the  various  forms 
of  opacities  observed  in  the  vitreous  body  after  a  fibrino-plas- 
tic  exudation  into  it. 

The  most  common  forms  of  opacities  in  the  vitreous  body  are 
the  so-called  muscce  volitantes  {mouches  volantes).  A  patient  suf- 
fering from  such  muscae  volitantes,  when  he  looks  at  a  bright  sur- 
face, sees  small  black  and  gray  dots  and  threads  on  or  in  front  of 
it,  which  seem  to  float  and  to  "run  away"  whenever  he  tries  to 
*'look  directly  at  them."  These  dots  and  threads  often  present 
the  appearance  of  strings  of  beads,  and  also  take  on  other 
quaint  shapes.  What  the  patient  really  observes  are  the  shad- 
ows cast  upon  the  retina  by  fibrinous  threads  or  by  small  ag- 
gregations of  cellular  elements  in  the  vitreous  body. 

The  presence  of  such  minute  cellular  elements  and  fine 
threads  may  be  demonstrated  in  the  normal  eye;  therefore, 
muscae  volitantes  are  not  necessarily  to  be  interpretated  as  a 
pathological  symptom.  When  a  person  has  once  detected 
their  existence  he  is  apt  to  look  for  them  again,  and  then  he 
finds  to  his  dismay  that  they  apparently  increase  in  number^ 
although  in  fact  he  simply  sees  now  opacities  to  which  he  had 

—196— 


DISEASES  OF  THE  VITREOUS  BODY.  197 

previously  paid  no  attention.  This  discovery  may  bring  him 
to  the  physician. 

The  sudden  appearance  of  muscae  volitantes  in  an  eye,  or  the 
actual  and  rapid  increase  in  their  number,  where  they  have  been 
present  and  noticed  before,  is  to  be  looked  upon,  especially  in 
short-sighted  persons,  as  an  indication  of  a  disturbance  in  the 
uveal  tract,  and,  therefore,  as  an  important  symptom. 

With  this  exception,  muscae  volitantes,  as  a  rule,  call  for  no 
treatment,  and,  if  we  once  succeed  in  convincing  the  patient 
of  the  fact  that,  although  possibly  annoying,  they  are  really  of 
no  importance,  his  anxiety  is  relieved,  and  they  usually  cease 
to  be  troublesome. 

Opacities  in  the  vitreous  body,  when  they  are  extensive 
enough  to  be  detected  by  the  ophthalmoscope,  whether  as  con- 
spicuous films  or  flocks,  or  as  denser  membranes,  or  as  a  gen- 
eral diffused  muddiness,  are  of  far  greater  importance. 

In  such  cases  the  opacities  materially  interfere  with  sight, 
and  they  are  moreover,  the  evidence  of  the  actual  or  former 
existence  of  a  fibrino-plastic  choroiditis.  They  are  often 
found  in  highly  myopic  eyes.  The  vitreous  body  is  then  usu- 
ally fluid,  and  the  dense  shadows  fly  about  with  every  move- 
ment of  the  eyeball. 

Even  when  the  choroiditis,  which  has  given  rise  to  the  form- 
ation of  such  opacities,  is  cured,  we  may  try  to  bring  about 
their  absorption.  Mercury,  decoctum  Zittmannii^  iodide  of 
potassium,  the  constant  current,  and  the  muriate  of  pilocar- 
pine, are  useful  remedies  in  such  cases.  Subconjunctival  injec- 
tions of  mercury  have  of  late  been  advocated  {Darier).  In 
other  cases  large  membranous  opacities  have  been  torn  with 
success  by  means  of  a  small  cutting  instrument. 

Newformations  of  large  masses  of  connective  tissue  within 
the  vitreous  body  are  rare,  but  when  present  they  seriously 
interfere  with  sight.  They  lie  usually  near  the  optic  nerve 
entrance,  and  are  due  to  inflammation  of  the  optic  nerve  or 
retina  {retinitis  proliferans). 

Synchisis  scintillans  is  the  name  given  to  a  liquified  condi- 
tion of  the  vitreous  body  in  which  crystals  (mostly  of  choles- 
terine)  have  been  formed.     When  these  fly  about  they  sparkle 


198  OPHTHALMOL  OGY. 

in  the  light  like  particles  of  silver  or  gold.  We  know  of  no 
treatment  for  this  condition. 

Hcemorrhages  into  the  vitreous  body  (hcemophthalmus)  may 
occur  spontaneously  from  retinal  bloodvessels,  or  are  observed 
to  accompany  injuries  to  the  ciliary  body,  the  choroid  or  the 
retina.  We  shall  speak  further  about  them  in  Chapter  XVIII. 
If  the  eye  in  such  a  case  is  examined  with  the  ophthalmo- 
scope, it  may  at  first  be  impossible  to  get  any  reflex  from  the 
back-ground,  or  a  darker  or  lighter  shade  of  red  may  be  seen 
according  to  the  quantity  of  blood  effused  into  the  vitreous 
body.  Such  haemorrhages  may  become  perfectly  absorbed, 
or  the  fibrine  may  remain  and  form  floating  or  membranous 
opacities.  If  the  haemorrhage  is  very  extensive,  the  eyeball 
will   probably  become  atrophied. 

The  conditions  caused  by  the  presence  of  a  foreign  body  in 
the  vitreous  will  be  detailed  in  Chapter  XVIII. 


CHAPTER    XVII.-GLAUCOMA. 

§103.  Glaucoma  {ophthalmia  arthritic  a,  choroiditis  serosa)  is 
an  affection  of  the  eye  the  nature  of  which  is,  as  yet,  not  per- 
fectly understood.  Its  destructiveness  and  the  insiduous  slow 
progress  of  some  of  its  varieties,  make  it  a  disease  of  very 
grave  importance.  The  general  practitioner  should  be  perfect- 
ly familiar  with  its  chief  symptoms,  the  more  so  since  they 
are  of  such  a  nature  as  to  bring  the  patient  to  seek  aid  from 
the  physician  quite  as  often  as  from  the  oculist. 

The  name  glaucoma  is  as  dark  as  the  disease,  and  in  the 
present  state  of  our  knowledge  has  little  meaning.  It  used  to 
be  said  that  glaucomatous  eyes  have  a  greenish  pupil,  and  for 
this  reason  the  name  has  been  given  to  the  disease.  The 
greenish  pupil  is,  however,  but  rarely  seen.  The  name,  there- 
fore, is  a  misnomer. 

The  cardinal  symptoms  of  glaucoma  are,  an  increase  of  the 
intraocular  tension,  which  renders  the  eyeball  harder  than  it  is 
in  its  normal  condition,  and  the  loss  of  vision  which  is  chiefly 
(especially  in  the  later  stages),  but  not  solely,  due  to  the  exca- 
vation and  subsequent  atrophy  of  the  optic  papilla.  The  in- 
creased intraocular  tension  must,  of  necessity,  even  before 
real  atrophy  of  the  nerve  has  begun,  interfere  with  the  blood 
supply  to  the  retina,  and  will,  if  strong  enough,  bring  about 
an  interference  with  the  ductile  faculty  of  the  nerve-fibres  in 
this  membrane.  According  to  the  degree  of  increase  of  intra- 
ocular tension  we  designate  it  as  -|-T  (+Ti,  +T2,  -I-T3).  (See 
Chapter  IV). 

Around  the  two  cardinal  symptoms,  viz.:  increased  tension 
and  loss  of  vision,  other  symptoms  may  be  grouped  which 
characterize  the  different  stages  and  forms  of  the  disease. 
With  regard  to  the  stages  we  differentiate  between  the  pro- 
dromal stage,  glaucoma  evolutmn,  and  glaucoma  absolutum. 
When  glaucoma  attacks  an  eye  without  being  preceded  by 
some  other  disease  likely  to  produce    it,  we  speak  of  primary 

—199— 


200  OPHTHALMOLOG  Y, 

glaucoma;  when  the  reverse  is  the  case  we  speak  of  secondary 
glaucoma. 

§104.  The  prodromal  symptoms  must  be  considered  really 
as  mild  attacks  of  glaucoma.  They  may  be  little  noticed  by 
the  patient  or  may  alarm  him  sufficiently  to  seek  aid.  This 
stage  of  the  disease  may  cover  a  period  of  months  and  even 
years.  The  early  recognition  of  this  condition  is  the  more 
important  as  the  disease  at  this  stage  is  usually  much  more 
tractable  than  at  a  later  one.  As  prodromal  symptoms  the 
patients  observe  recurring  attacks  of  dimness  of  vision  of 
varying  degree.  Rainbow  colored  rings  may  at  the  same  time 
be  seen  around  the  gas  or  candle  flame,  similar  to  those  ap- 
pearing to  a  normal  eye  when  viewing  a  light  through  a  win- 
dow bespattered  with  minute  rain-drops  in  a  misty  atmos- 
phere. The  range  of  accommodation  is  reduced,  and  in  con- 
sequence presbyopia  is  developed  at  an  abnormally  early 
period  of  life,  or  an  existing  presbyopia  rapidly  increases.  In 
some  cases  myopia  develops  when  the  whole  of  the  crystalline 
lens  is  pushed  forward  and  the  fibres  of  the  suspensory  liga- 
ment are  stretched.  There  may  be  pain  connected  with  the 
attacks  of  dimness  of  vision  which  varies  considerably.  Some- 
times it  is  but  slight,  in  other  cases  it  is  excruciating  and  ex- 
tends from  the  eye  to  the  neighborhood,  and  even  to  the  back 
of  the  head.  It  may  also  lead  to  nausea  and  vomiting.  As 
soon  as  vision  is  permanently  reduced,  the  glaucoma  has  passed 
from  the  prodromal  stage  to  that  of  glaucoma  evolutum. 

The  forms  in  which  glaucoma  evolutum  is  most  frequently 
observed  are  simple  chronic  glaucoma,  acute  inflammatory 
glaucoma,  and  chronic  inflammatory  glaucoma. 

§105.  In  simple  chronic  glaucoma  the  eye  usually  shows  no 
external  signs  of  disease.  The  chief  symptoms  are  the  loss 
of  visual  acuteness,  the  (sometimes  imperceptible)  increase  of 
intraocular  tension  and  the  excavation  of  the  optic  papilla. 
The  so-called  physiological  excavation  of  the  optic  papilla  has 
no  sharp  edge  and  never  reaches  close  to  the  periphery  of  the 
papilla.  A  typical  glaucomatous  excavation  has  a  sharp  edge, 
reaches  very  close  to  the  periphery  of  the  papilla  and  is  often 


GLAUCOMA.  201 

much  deeper  than  the  physiological  excavation.  When  a 
glaucomatous  disk  is  viewed  with  the  ophthalmoscope  the  ar- 
rangement of  the  bloodvessels  is  very  striking.  There  is  usu- 
ally a  yellowish  ring  around  the  periphery  of  the  papilla  due 
to  the  stretching  and  consequent  atrophy  of  the  choroid. 
When  the  bloodvessels  have  passed  this  ring  in  the  direction 
towards  the  papilla,  they  bent  abruptly  over  the  edge  of  the 
disk  disappear  partly  or  totally  (See  Fig.  82)  and  reappear  in  a 
parallactic  deflection  at  the  bottom  of  the  excavation.  If  the 
excavation  is  deep,  the  parts  adjoining  its  rim  and  those  lying 
in  the  depth  of  it,  cannot  be  seen  plainly  at  one  and  the  same 
time.  By  this  means  the  depth  of  a  glaucomatous  excavation 
may  be  measured  with  the  ophthalmoscope. 


Fig.  82. — Ophthalmoscopic  appearance  of  a  glaucomatous  excavation.     The  atro- 
phied nerve  fibres  allow  the  lamina  cribrosa  to  be  seen  as  dark  points. 

At  the  bottom  of  the  excavation  the  optic  nerve  appears 
punctated.  This  is  due  to  the  atrophy  of  the  nerve-fibres 
which  allow  the  net-work  of  the  lamina  cribrosa  to  be  seen. 
There  is  often  a  spontaneous  pulsation  of  the  arteries,  or  this 
symptom  may  be  readily  produced  by  pressure  on  the  eye- 
ball. 

As  the  visual  acuteness  becomes  gradually  lessened  by  the 
growing  excavation  of  the  papilla  and  atrophy  of  the  nerve  fibres, 
central  vision  (central  scotoma),  as  well  as  peripheral  vision 
become  affected.  The  corUraction  of  the  visual  field  begins  most 


202  OPHTHALMOLOGY. 

ly  on  the  nasal  side  and  extends  gradually  upward  and  down 
ward.  Finally,  the  visual  field  may  be  represented  by  a  small 
elliptical  space,  with  the  fixation  point  near  its  nasal  focus.  Dur- 
ing the  progress  of  these  symptoms  the  light  sense  becomes 
also   diminished.     Color  perception  remains  good. 

§io6.  \xv  acute  inflammatory  glaucoma  the  disease  attacks 
the  eye  suddenly,  oftenest  at  night.  It  makes  itself  known 
particularly  by  excruciating  pain  in  the  eye  and  head,  some- 
times combined  with  nausea  or  vomiting.  There  is  usually  a 
hypersecretion  of  tears  and  watery  discharge  from  the  nose, 
and  oedema  of  the  upper  eyelid.  The  admission  of  light  into 
the  eye  causes  the  pain  to  increase.  The  conjunctival  and 
episcleral  bloodvessels  are  found  hyperaemic,  as  in  severe  iritis, 
the  veins  are  particularly  tortuous.  The  cornea  is  steamy  and 
almost  anaesthetic  to  the  touch.  The  eyeball  is  hard.  The 
anterior  chamber  is  shallow,  its  contents  are  muddy,  the  pupil 
is  wider  than  normal  and  acts  sluggishly,  or  not  at  all.  No 
details  of  the  back-ground  of  the  eye  can  be  seen,  often  not 
even  a  red  reflex.  Vision  may  be  reduced  to  the  bare  per- 
ception of  light. 

Such  an  attack  may  last  a  few  hours  or  cover  several  weeks. 
When  the  attack  has  passed  off,  vision  may  again  be  quite  good. 
Other  acute  attacks  may  follow,  or  this  form  may  pass  over 
into  the  chronic  form  of  inflammatory  glaucoma. 

In  a  few  rare  cases  one  such  attack  is  known  to  have  de- 
stroyed vision  absolutely  {glaucoma  fulminans). 

§107.  Chronic  inflammatory  glaucoma  is  the  form  in  which 
the  disease  is  most  frequently  observed.  It  may  follow  an 
acute  attack  or  develop  slowly.  The  external  symptoms  of 
inflammation  are  less  marked  but  are  all  visible.  The  cornea 
may  be  clear  or  hazy.  The  anterior  chamber  is  swollen,  the 
pupil  wide  and  acts  sluggishly  or  is  immoveable.  The  iris  be- 
comes discolored,  its  tissue  atrophies.  The  intraocular  ten- 
sion is  increased.  The  optic  papilla  is  excavated.  There  are 
attacks  of  pain  especially  at  night,  and  vision  is  gradually  de- 
stroyed. 

When  by  any  of  these  forms  of  glaucoma  sight  has  become 


GLA  UCOMA.  203 

abolished,  we  speak  of  glaucoma  absolutum.  The  disease, 
however,  progresses  still  further.  The  eye  remains  painful. 
The  lens  is  pressed  forward  till  it  touches  the  cornea  and  be- 
comes cataractous  ^glaucomatous  cataract).  The  cornea  may- 
become  ulcerated  and  even  perforated,  or  scleral  staphyloma 
may  develop.  In  short,  the  patient  gets  no  relief  until  the 
eye  is  removed. 

§io8.  Secondary  glaucoma  follows  various  diseases  of  the 
eye.  The  most  frequent  among  these  are:  seclusion  and  occlu- 
sion of  the  pupil  by  plastic  iritis,  serous  iritis,  serous  choroiditis, 
haemorrhages  into  the  tissue  of  the  retina  (probably  due  to  the 
same  cause  as  the  seemingly  secondary  glaucoma)  {glaucoma 
hcemorrhagicum),  rapid  swelling  of  the  lens-substance  when  the 
lens-capsule  has  been  ruptured  intentionally  or  by  an  accident, 
dislocation  of  the  lens,  especially  into  the  anterior  chamber, 
scleral  staphyloma,  intra-ocular  tumors,  and  some  forms  of 
keratitis  (vesicular  and  ribbon-shaped  keratitis). 

§109.  Glaucoma  is  observed  in  about  one  per  cent,  of  the 
eye  patients,  and  is  more  frequent  among  females  than  among 
males.  It  rarely  attacks  patients  under  fifty  years  of  age.  It 
may  affect  one  eye  only  at  a  time,  but  the  fellow  eye  almost 
invariably  falls  a  victim  to  the  disease  at  some  later  period. 
Sometimes  an  operation  on  the  first  affected  eye  seems  to 
hasten  the  attack  in  the  fellow  eye.  Eyes  that  are  hyperme- 
tropic or  astigmatic  are  more  prone  to  be  afflicted  with  glau- 
coma.    In  rare  cases  it   has  been  seen  to  attack  myopic  eyes. 

It  may  be  well  to  state  here  that  when  the  symptoms  com- 
plained of  by  a  patient  point  at  all  to  glaucoma,  the  physician 
should  not  instill  sulphate  of  atropia,  hydrobromate  of  homa- 
tropine,  or  even  cocaine  into  the  patient's  eye,  as  mydriatics 
are  apt  to  bring  about  an  acute  attack. 

§110.  The  anatomical  changes  found  in  glaucomatous  eyes 
are  grouped  particularly  around  the  optic  papilla  and  nerve, 
and  the  ciliary  body  and  the  iris-angle. 

The  most  striking,  invariably  characteristic  histological 
change  is  the  excavation    of  the  optic  papilla   and  atrophy  of 


204  OPHTHALMOLOGY. 

the  optic  nerve  fibres.  (See  Fig  83).  In  a  longitudinal  sec- 
tion through  these  parts  it  is  seen  that  the  bottom  of  the  ex- 
cavation lies  behind  the  level  of  the  choroid.  The  meshes  of 
the  lamina   cribrosa  are  closely   pressed   together  and   some- 


FiG.  83. — ^Very  deep  glaucomatous  excavation  of  the  optic  papilla.  The  nerve  fibres 
are  pressed  aside  and  atrophied.  The  lamina  cribrosa  is  pressed  out  of 
sclerotic.    The  optic  nerve  is  atrophied. 

times  this  portion  of  the  sclerotic  forms  a  convex  line  with  its 
convexity  reaching  beyond  the  posterior  surface  of  the  sur- 
rounding sclerotic.  A  few  nerve-fibres  are  seen  lying  in  front 
of  the  lamina  cribrosa,  and  lining  the  walls  of  the  excavation 
and  then  to  join  the  retina.  Few  bloodvessels  are  found  and 
the  veins  are  considerably  wider  than  in  the  normal.  At  the 
edge  of  the  excavation  the  retina  and  choroid  are  drawn  down 
into  it  and  towards  its  axis  and  are  atrophic.  The  choroidal 
bloodvessels  around  the  optic  papilla  are  mostly  obliter- 
ated and  the  pigment  granules  of  destroyed  cells  lie  free  in 
the  neighboring  sclerotic.  Sometimes  small  nests  of  infiltra- 
tion are  found  in  the  choroid  near  the  excavation.  The  optic 
nerve  farther  back  is  atrophied  and  the  connective  tissue  tra- 
beculae  are  very  much  thicker  than  normal. 

The  dilatation  and    rigidity  of  the   pupil   are  explained    by 
the  adhesion  of  the  periphery  of  the    iris  to  the  posterior  sur- 


GLAUCOMA. 


205 


face    of  the    cornea   (See   Fig.  84),    due   to    the   proliferation 
of    Descemet's    endothelium    and    the    new     formation    of  a 


Fig.  84. — Adhesion  between  the  periphery  of  the  iris  and  cornea  as  observed  in 
glaucoma. 

small  quantity  of  connective  tissue.     In  this  manner  Fontana's 
spaces  are  obliterated.     In  recent  cases  round  cell  infiltration 


Fig.  85. — Swollen  and  hypersemic  ciliary  body  in  glaucoma. 

is  found  in  the  corneo-scleral  tissue.  Schlemm's  canal  is  some- 
times pervious,  sometimes  closed.  This  adhesion  of  the  per- 
iphery of  the  iris  to  the  cornea  may  be  due  to  the  general  in- 
crease of  the  intraocular  pressure,  or  to  direct  pressure  on  the  iris 
and  lens  by  the  swollen  and  hyperaemic  ciliary  body  {Braileyy 
Weber).     (See  Fig.  85).     Later  on  the  ciliary  body  and  iris  are 


206  OPHTHALMOLOGY. 

found  to  be  atrophied  and  many  of  the  bloodvessels  are  oblit- 
erated.    (See  Fig.  86). 


Fig.  86. — Atrophic  iris  and  ciliary  body  as  they  appear  in  the  later  stages  of  glau- 
coma.    Schlemm's  canal  is  obliterated. 

These  are  in  the  main  the  pathological  changes  found  in 
glaucomatous  eyes,  and  they  but  partially  explain  the  symp- 
toms of  this  still  mysterious  disease. 

To  unite  and  explain  all  symptoms  of  glaucoma  by  one  com- 
mon cause  has  been  the  aim  of  a  large  number  of  theoretic 
endeavors.  Those  that  probably  come  most  near  to  the  truth 
see  this  cause  for  all  the  symptoms  in  a  disproportion  between 
the  quantity  of  fluid  secreted  into  the  interior  of  the  eyeball 
and  the  amount  excreted  from  it.  This  may  come  about  by 
an  abnormal  increase  of  secretion  {^Graefe^  Arlt,  Sattler)^  by  a 
venous  stasis  {Stellwag,  Mauthner),  or  by  the  obstruction  of 
the  natural  channels  of  drainage  without  any  hypersecretion 
{Knies^  Ulrich,  Priestley-Smith,  Brailey,  Weber).  Schoen  more 
recently  sees  the  cause  of  glaucoma  in  an  overstrain  of  the  ac- 
commodation, in  hypermetropic  and  astigmatic  eyes  especially, 
and  in  its  mechanical  influence  upon  the  structures  of  the  eye- 
ball. Some  authors  think  the  excavation  is  chiefly  due  to 
changes  in  the  minute  bloodvessels  {Haller's  ring)  which  lie 
in  the  sclerotic  arund  the  optic  nerve  entrance  {Jceger,  Schna- 
bely  Kleiri).  Risley  most  recently  tried  to  establish  on  a  better 
basis  and  with  more  strength  an  older  theory,  that  glaucoma 
is  due  to  gout,  by  drawing  attention  to  the  similarity  between 


GLAUCOMA.  207 

an  acute  attack  of  gout  with  one  of  glaucoma  (ophthalmia  ar- 
thritic a). 

All  of  these  theories,  and  a  number  not  mentioned  here,  seem 
to  give  some  true  explanation  of  one  or  the  other  group  of 
symptoms.     Yet,  not  one  covers  the  ground  fully. 

§112.  Unless  interrupted  by  treatment  in  its  progress  glau- 
coma always  leads  to  blindness.  This  treatment  may  be  med- 
ical or  surgical,  and  is  the  more  successful  the  earlier  the  stage 
of  the  disease.  As  is  well  known,  the  miotic  drugs  not  only 
contract  the  pupil  but  also  reduce  the  intraocular  pressure 
(physostigmine,  sulphate  of  eserine,  muriate  of  pilocarpine). 
The  instillation  of  one  of  these  drugs  may  act  very  benificially 
in  the  prodromal  stage  or  may  even  cut  short  mild  acute  at- 
tacks, yet  the  effect  is  not  lasting.  As  a  rule,  the  progress  of 
the  disease  can  only  be  brought  to  an  end  by  surgical  means. 
The  chief  of  these  is  iridectomy.  It  has  become  fashionable 
to  divest  great  geniuses  of  their  glory,  but  all  that  has  been 
said  to  the  contrary  cannot  rob  Von  Graefe  of  the  laurels,  won  by 
teaching  the  fact  that  an  iridectomy  will  heal  a  glaucoma.  The 
knowledge  that  in  a  number  of  cases  it  is  not  followed  by 
success,  and  in  a  smaller  number  seems  even  to  hasten  the  de- 
struction of  a  glaucomatous  eye,  should  not  induce  us  to 
withhold  from  the  majority  of  the  patients  the  benefit  of  this 
operation.  Its  value  is  undoubted  in  acute  and  chronic  in- 
flammatory glaucoma,  while  in  simple  chronic  glaucoma  it  is 
least  successful.  The  manner  in  which  an  iridectomy  will 
lastingly  reduce  the  intraocular  pressure  is  not  fully  under- 
stood. 

In  stead  of  iridectomy,  sclerotomy  has  been  introduced  by 
Quaglino^  Wecker  and  others.  It  has  proven  to  be  almost  use- 
less in  the  inflammatory  forms  of  glaucoma,  while  in  simple 
chronic  glaucoma,  or  after  an  iridectomy  has  not  proven  fully 
successful,  it  may  be  resorted  to.  Other  operative  measures, 
like  Hancock' s  cut  through  the  ciliary  muscle,  or  tenotomy  of 
the  ciliary  muscle,  are  hardly  worth  mention. 


CHAPTER     XVIII.— INJURIES     OF     THE    EYEBALL 
AND    THEIR    CONSEQUENCES. 

§113.  Injuries  to  the  eyeball,  especially  when  the  foreign 
body  which  has  caused  the  injury  remains  lodged  in  the  eye, 
are  of  the  gravest  importance.  Their  prognosis,  except  when 
they  are  superficial  only,  must  always  be  a  doubtful  one  at  first, 
as  we  have  no  means  by  which  to  judge  whether  the  offend- 
ing substance  was  aseptic  or  whether  at  the  very  moment  the 
injury  was  inflicted,  septic  matter  was  carried  into  and  became 
lodged  within  the  tissues  of  the  eye.  Even  when  such  an  in- 
fection did  not  take  place  at  the  time  the  injury  happened,  the 
contents  of  the  conjunctival  sack  may  have  produced  a  second- 
ary infection  when  the  patient  is  seen  or  produce  it  afterwards. 

It  is  our  duty,  therefore,  whenever  we  have  to  deal  with  an 
injury  to  try  at  once  by  all  means  to  render  the  eyeball  and 
the  conjunctival  sack  aseptic,  and  to  keep  it  so,  as  much  as 
possible,  until  the  injury  is  healed. 

When  septic  infection  has  taken  place  and  its  results  are 
already  evident  when  we  first  see  the  patient,  our  means  of 
combatting  it,  except  in  superficial  wounds,  are  but  small,  in- 
deed. 

As  the  general  practitioner  is  very  often  the  first  one  to  see 
such  cases,  he  should  always,  before  doing  anything  else,  try  to 
render  the  wounded  eye  aseptic.  This  is  accomplished  by 
carefully  removing  all  foreign  matter  and  flushing  the  conjunc- 
tival sack  repeatedly  with  a  solution  of  bichloride  of  mercury 
(i  in  3  to  5>ooo),  or  a  four  per  cent,  solution  of  boracic  acid,  or 
by  dusting  iodoform  or  aristol  into  the  conjunctival  sack  or  by 
staining  the  tissue  with  pyoktanine.  Whichever  remedy  is  used 
it  must  be  used  in  sufficient  quantity,  and  the  rule  should  be  to 
use  rather  too  much  than  too  little.  If  necessary  atropine 
must  be  instilled.  Immediately  after  the  use  of  the  antiseptic 
and  when  a  condition  of  comparative  asepsis  has  been  produced, 
the  eye  must  be  closed,  and  this  is  best  done  in  the  manner  des- 

—208— 


INJURIES  OF  THE  EYEBALL,  209 

cribed  in  Chapter  VI,  by  absorbent  cotton  saturated  with  bichlo- 
ride of  mercury  and  adhesive  plaster.  In  this  manner  we  may 
succeed  in  keeping  the  eye  sufficiently  aseptic  to  prevent  infec- 
tion of  the  wound,  if  it  has  not  yet  taken  place,  and  to  render 
an  established  superficial  infection  harmless.  If  there  is  any 
obstruction  to  the  tear-drainage  and  stagnation  of  the  tear-fluid 
in  the  lachrymal  sack,  this  must  at  once  be  attended  to,  as  the 
lachrymal  sack  is  under  such  circumstances  apt  to  contain  a 
great  deal  of  infectious  material.  If  a  superficial  wound 
shows  the  results  of  an  infection  by  the  formation  of  pus  and 
necrosis,  there  is  no  remedy  higher  to  be  prized  than  the  im- 
mediate destruction  of  the  infected  portion  by  galvano-cautery 
or  the  actual  cautery.  If  these  are  not  at  hand,  cauterization 
with  nitrate  of  silver  or  pure  carbolic  acid  may  take  the  place. 
If  the  infection  concerns  the  tissue  in  the  depth  of  the  an- 
terior chamber,  opening  the  chamber  and  washing  it  out  with 
a  warm  boracic  acid  or  weak  sublimate  solution  is  often  still 
valuable.  If  the  infective  material  has  been  deposited  in  the 
portions  of  the  eyeball  lying  farther  backwards,  subconjuncti- 
val injections  of  a  solution  of  bichloride  of  mercury  or  even 
intra-ocular  injections  of  chlorine  water  should  be  tried. 
Atropine  should  be  instilled  in  these  cases. 

§114.  In  the  foregoing  we  contemplated  injuries  without 
the  retention  of  a  foreign  body  (except  the  infectious  material) 
within  the  tissues  of  the  eye.  The  rules,  here  given,  hold  good, 
even  if  a  foreign  body  is  retained.  To  these  measures, 
however,  must  then  be  added  the  removal  of  the  foreign  body, 
where  it  is  possible.  The  manner  in  which  this  has  to  be 
accomplished  will  be  detailed  farther  on.  Aside  from  the  dan- 
ger of  infection,  all  injuries  to  the  eye  are  apt  to  influence  un- 
favorably its  further  usefulness  as  an  organ  of  vision  in  some 
measure. 

Simple  cuts  in  the  cornea,  which  do  not  penetrate  its  whole 
thickness,  heal,  as  a  rule,  without  trouble  and  without  interfer- 
ence. When  they  are  originally  or  become  later  on  infected 
they  lead  to  local  infiltration,  and  the  formation  of  a  necrotic 
ulcer  with  all  its  consequences.  Every  cut  necessarily  leaves 
a  scar,  which  according  to  its  size  and  situation,  will  interfere 
more  or  less  with  sight. 


210  OPHTHALMOLOG  Y. 

If  a  cut  has  penetrated  the  whole  thickness  of  the  cornea, 
the  aqueous  humorescapesand  the  anterior  chamber  is  emptied. 
When  this  happens,  the  contents  of  the  posterior  part  of  the 
eyeball  are  pressed  forward,  so  that  the  iris,  or  crystalline  lens, 
comes  in  contact  with  the  inner  opening  of  the  corneal  wound 
and  plugs  it,  or  becomes  caught  between  its  lips  {incarceration) 


Fig.  87. — A  fold  of  iris-tissue  is  incarcerated  in  a  corneal  scar. 

(See  Fig.  87).  In  other  cases  the  iris  is  carried  through  the  wound 
canal  to  the  surface  of  the  cornea  and  beyond,  and  is  held  in 


Fig.  88. — Recent  prolapse  of  the  iris  through  a  corneal  wound.    The  epithelium   of 
the  cornea  is  beginning  to  grow  over  the  prolapsed  iris. 

this  position  {prolapse)  (See  Fig.  88).    This  prolapse  may  give 
rise  to   further   troubles.      The   portion  of  the    iris  which  lies 


INJURIES  OF  THE  EYEBALL,  211 

outside  the  cornea  is,  as  a  rule,  gradually  cast  off  or  shrinks, 
since  by  the  constriction  it  is  deprived  of  its  nutrition.  In 
other  cases,  when  the  nutrition  is  not  cut  off,  it  may  simply 
become  covered  with  corneal  epithelium  or  it  becomes  the 
starting  point  of  a  granuloma,  and  then  it  grows  as  far  as  the 
eyelids  will  allow  it.    (See   Fig.  89).   Prolapse  as  well  as  incar- 


FiG.  89. — A  prolapse  of  the  iris  due  to  an  injury  has  given  rise  to  the  formation  of  a 
granuloma  (traumatic  granuloma  of  the  iris). 

ceration  of  the  iris,  produce  what  is  called  anterior  synechia 
of  the  iris.  The  pupil  in  these  cases  is  drawn  towards  the 
scar  which  usually  gives  it  a  pear-shaped  appearance,  and  every 
contraction  of  the  sphincter  pupillae  muscle  pulls  at  this  false 
insertion  of  the  iris.  This  may  give  rise  to  a  chronic  state  of 
irritation  in  this  membrane,  and  ultimately  to  serious  disturb- 
ances, such  as  iritis  and,  perhaps,  glaucoma.  We  should,  there- 
fore, in  the  beginning,  do  what  is  in  our  power  to  restore  the  iris 
to  its  normal  position  within  the  eye.  Gently  rubbing  the 
cornea  with  the  eyelids,  or^prying  the  wound-lips  apart  with  a 
thin  curette,  or  directly  pushing  the  iris  into  its  normal  posi- 
tion by  means  of  a  spatula,  may  sometimes  suffice  not  only  to 
liberate  the  incarcerated  iris,  but  to  keep  it  also  from  again 
prolapsing.  If  the  injury  is  very'recent,  the  action  of  a  miotic 
helps  in  bringing  about  the  desired  effect.  If  the  iris  remains 
prolapsed,  it  is  best  to  cut  off  the  prolapsed  part,  and  free  the 
remaining    iris    altogether   from  its  attachment  to  the  corneal 


212  OPHTHALMOLOG  Y. 

wound.  This  will  virtually  amount  to  making  an  iridectomy, 
and  can  be  done  even  a  few  days  after  the  prolapse  of  the 
iris  has  occurred. 

In  some  cases,  on  account  of  the  presence  of  the  iris,  al  • 
though  it  does  not  protrude  over  the  surface  of  the  cornea,  the 
scar  cannot  become  strong  enough  to  withstand  even  the  nor- 
mal intraocular  pressure,  and  thus  it  begins  gradually  to  bulge 
{ectatic,  cystoid scar),  and  may,  after  a  time,  develop  into  a  trau- 
matic staphyloma,  (See.  Fig.  90).  In  rare  cases  the  incarceration 


Fig.  91. — Cystoid  scar  formed  by  atrophied  iris  tissue  and  corneal  epithelium  cov- 
ering it. 

may  give  rise  to  the  formation  of  a  cyst  of  the  iris.  The  nearer 
the  periphery  of  the  iris  the  incarceration  or  the  prolapse  has 
taken  place,  the  more  serious  are  the  consequences  which  may 
follow.  The  most  serious  of  these  are  chronic  plastic  or  pur- 
ulent iritis  and  cyclitis,  and  finally  sympathetic  ophthalmia. 

If  the  cut  has  penetrated  both  the  cornea  and  the  iris,  the  con- 
ditions will  be  much  the  same  as  in  simple  penetrating  wounds 
of  the  cornea.  There  is,  however,  usually  a  large  effusion  of 
blood  into  the  anterior  chamber,  which  may  interfere  for  a  time 
with  a  careful  examination. 

If  the  cut  is  still  deeper  and  penetrates  the  capsule  of  the 
crystalline  lens,  the  situation  is  further  complicated  by  the 
formation  of  cataract.  If  the  wound  in  the  lens-capsule  is 
large  the  pressure  from  the  rapidly  swelling  lens-substance, 
giving  rise  to  acute  glaucomatous  symptoms,  may  very  soon 
force  us  to  attempt  its  extraction.  In  some  rare  cases  the  iris, 
without  apparently  being  cut,  may,  by  the  injuring  material, 
be  driven  into  the  crystalline  lens,  and  may  remain  in  this  po- 
sition, held  tight  by  the  lips  of  the  wound  in  the  lens-capsule. 
The  ensuing  dimness  of  the  lens-substance  may  then  remain 
confined  to  the  immediate  neighborhood  of  such  a  traumatic 


INJURIES  OF  THE  EYEBALL,  213 

posterior  synechia.  In  some  cases  the  iris,  or  the  iris  to- 
gether with  the  crystalline  lens,  are  torn  out  of  the  eyeball 
altogether  by  the  instrument  inflicting  the  injury  (traumatic 
irideremia). 

Traumatic  cataract  may  be  removed  by  extraction,  or  in 
young  individuals  it  may  be  brought  to  absorption  by  means 
of  discission.  In  aseptic  injuries  the  cataract  remains  often 
uncomplicated  save  for  the  small  scar  in  the  cornea.  When 
the  injury  was  attended  with  septic  infection  serious  compli- 
cations usually  develop  before  the  formation  of  the  cataract  or 
with  it.  Iritis  and  iridocyclitis  may  render  the  condition  of 
the  eye  less  favorable  for  future  operation  or  by  their  sequelae 
may  make  it  impossible  to  give  more  than  a  small  portion  of 
useful  vision.  If  deeper  complications  ensue  the  eye  becomes 
very  painful,  blind  and  dangerous  to  its  fellow,  and  will 
have  to  be  removed. 

Injuries  to  the  slerotic  happen  but  rarely  without  a  contem- 
poraneous injury  to  the  ciliary  body,  or  to  the  choroid  and 
retina.  When  such  a  wound  has  been  rendered  aseptic  and  is 
not  gaping,  rest  and  closure  of  the  eye  may  accomplish  all 
that  is  required;  but  if  the  wound  gapes  widely,  and  the  vit- 
reous body  shows  itself  in  the  opening,  it  is  best  to  sew  it  up 
by  stitching  the  wound-lips  of  the  conjunctiva  over  it,  or  those 
of  the  sclerotic.  Sometimes  the  vitreous  body  is  prolapsed 
and  the  cut  or  torn  edges  of  the  choroid  and,  perhaps,  also  of 
the  retina,  protrude  between  the  lips  of  the  wound  in  the  scle- 
rotic. In  such  cases  it  is  best  to  trim  the  edges  of  the 
wound  carefully  and  to  stitch  the  sclera  or  at  least  the  con- 
junctiva above  the  scleral  wound.  After  such  an  injury,  in 
spite  of  what  is  done,  the  eyeball  is  very  frequently  ruined, 
and  shrinks,  and  it  may  be  a  source  of  danger  to  the  fellow 
eye. 

If  a  septic  wound  of  the  sclerotic  lies  in  the  ciliary  region, 
and  the  ciliary  body  is  also  wounded,  septic  cyclitis,  in  spite 
of  our  efforts,  is  almost  sure  to  follow.  An  eyeball  so  injured 
will  shrink  and  is  especially  apt  to  cause  sympathetic  inflam- 
mation of  the  other  eye.  In  some  cases  the  injury  m^ay  in- 
volve almost  all  parts  of  the  eyeball,  and  the  eye  will  "run 
out,"  or  a  chronic  inflammatory  process  will  lead  to  shrinking. 


314  OPHTHALMOLOGY, 

Injuries  to  the  optic  nerve  are  not  often  seen.  They  are  di- 
rect cuts  or  tearing  by  bullets  or  other  foreign  substances 
penetrating  into  the  orbit.  They  lead  to  partial  or  total 
atrophy  of  the  nerve.  When  atrophy  of  the  optic  nerve  fol- 
lows an  injury  to  the  head,  as  from  a  heavy  fall,  etc.,  the  atro- 
phy is  usually  due  to  fracture  of  the  walls  of  the  canalis  op- 
ticus. 

§115.  If  the  injuring  foreign  body,  especially  when  septic, 
perforates  the  cornea  or  sclerotic  and  remains  lodged  within 
the  eyeball,  the  injury  is  a  particularly  grave  one,  as  stated. 

The  size  of  such  a  foreign  body  may  vary  considerably. 
Large  pieces  of  metal,  glass  or  wood  will  simply  destroy  the 
eyeball  by  the  immediate  injury  they  inflict  while  entering  it. 
Small  foreign  bodies  may  act  destructively  in  a  variety  of 
ways.  If  a  foreign  body  is  embedded  in  the  cornea,  it  is 
easily  removed  with  a  scoop  or  needle.  Care  must,  however, 
be  taken  not  to  push  it  through  the  cornea  into  the  anterior 
chamber  during  the  attempt  at  removal.  If  a  small  foreign 
body  has  entered  the  anterior  chamber,  it  will  usually  remain 
entangled  in  the  iris,  or  be  embedded  in  the  crystaUine  lens. 
If  it  remains  in  the  iris,  and  cannot  be  removed  in  any  other 
way,  an  iridectomy  of  the  part  which  contains  the  foreign  body 
ought  to  be  made.  If  it  remains  in  the  crystalline  lens,  it  usu- 
ally causes  simply  the  formation  of  a  cataract,  and  it  may  be 
removed  together  with  the  lens-substance  at  a  later  period. 

Sometimes  a  foreign  body,  after  having  struck  the  iris,  will 
fall  into  the  angle  between  the  iris  and  cornea,  and  its  removal 
from  such  a  position  is  very  troublesome,  especially  if  it  is 
not  iron  or  steel  and  very  small.  In  such  a  case  it  is  well  to 
move  the  foreign  body  with  a  needle  into  a  position  on  the 
iris  nearer  to  the  pupillary  edge,  and  then  to  remove  it,  with  a 
portion  of  the  iris,  by  iridectomy. 

Particles  of  iron  are  best  removed  by  means  of  a  perma- 
nent magnet  {Gruening' s)  or  better  by  means  of  an  electro- 
magnet {HtibbeTs). 

If  the  removal  of  a  foreign  body  in  the  iris  or  anterior  cham- 
ber can  be  accomplished  soon  after  it  has  entered  the  eyeball, 
the  danger  is  generally  averted.  We  should,  therefore,  remove 


INJURIES  OF'  THE  EYEBALL.  215 

such  a  foreign  body  as  soon  as  its  presence  is  known.  In  a 
few  instances  the  presence  of  an  aseptic  foreign  body  in  the 
anterior  chamber  has  been  borne  well  for  a  prolonged  period, 
but  such  cases  are  very  rare,  and  are  altogether   exceptional. 

Small  foreign  bodies  which  have  entered  the  vitreous  body 
may  be  detected  with  the  ophthalmoscope,  and  sometimes  can 
be  removed  by  its  guidance.  If  the  foreign  body  is  a  small 
piece  of  iron  or  steel,  we  may  succeed  in  remoying  it  by  the 
aid  of  a  magnet.  If  it  is  of  a  non-magnetic  substance,  a 
grooved  hook  (Knapp's)  or  smooth  forceps  may  be  used.  For 
these  purposes  the  sclerotic  must  be  cut  in  a  meridional  direc- 
tion, as  near  as  possible,  to  the  place  where  the  foreign  body 
is  situated.  If  not  removed,  septic  foreign  bodies  in  the  vit- 
reous body  give  rise  to  suppurating  panophthalmitis  or,  per- 
haps, to  a  lower  type  of  inflammation,  which  may  as  much  en- 
danger the  fellow-eye.  In  a  few  cases  an  aseptic  foreign 
body,  or  one  whose  chemical  decomposition  did  not  later  on 
act  as  an  irritant,  has  been  observed  to  remain  in  the  vitreous 
body  for  years,  doing  no  harm.  Even  when  an  eye  is  already 
inflamed  from  the  presence  of  a  septic  foreign  body  in  the 
vitreous,  the  removal  of  the  offending  body  may  sometimes 
arrest  the  progress  of  the  septic  inflammation. 

Foreign  bodies,  which  have  become  lodged  in  the  ciliary 
body,  almost  certainly  destroy  the  eyeball,  and  are  also  most 
frequently  the  source  of  the  destruction  of  its  fellow. 

From  the  foregoing  statements  it  is  easy  to  understand  that 
a  penetrating  injury  to  the  eye,  even  when  not  complicated 
with  infection  is,  in  most  cases,  a  very  serious  affair.  When 
complicated  by  septic  infection  the  gravity  is  still  greater,  as 
such  an  eye  is  in  most  cases  lost  and  may  destroy  its  fellow 
by  sympathetic  ophthalmia.  (See  Chapter  XIX).  The  phy- 
sician should,  therefore,  be  extremely  guarded  with  regard  to 
the  prognosis  in  all  such  cases,  since  even  an  apparently  slight 
injury  may  turn  out  to  have  been  a  most  serious  one.  We 
must  be  especially  careful  in  examining  an  injured  eyeball, 
and  in  doing  so,  as  much  as  possible,  avoid  pressure  upon  it. 
If  there  is  blood  in  the  anterior  chamber  preventing  further 
examination,  the  injury  is  probably  a  grave  one.  All  that  can 
be  done,  then,  is  to  wait  for  the  absorption   of  the  blood,  and 


216  OPHTHALMOLOGY. 

meanwhile  to  prevent,  as  far  as  possible,  the  development  of 
inflammatory  symptoms  by  antiseptics,  by  enjoining  strict 
rest  in  a  dark  room,  and  by  instilling  sulphate  of  atropia.  If 
after  a  few  days  no  inflammation  has  taken  place  and  the  blood 
is  absorbed,  so  that  the  deeper  parts  can  be  examined,  the 
eyeball  as  such  may  probably  be  considered  as  safe.  If  inflam- 
mation takes  place,  in  spite  of  our  precautions,  the  eyeball 
will  usually  be  lost  by  suppuration. 

Injured  eyeballs,  even  if  not  altogether  lost,  especially  when 
septic,  are  very  likely  to  remain  irritable  or  to  gradually  de- 
velop low  forms  of  chronic  inflammation,  which  may  lead  to 
to  their  destruction  later  on,  and  finally  to  the  destruction  of 
the  fellow  eye  through  sympathetic  disease.  Such  eyeballs 
must,  therefore,  be  constantly  and  closely  watched  so  as  to 
detect  the  danger  in  time  to  arrest  or  avert  it. 

It  is  plain  that  the  subject  of  injuries  to  the  eyeball  is  one 
of  the  greatest  importance,  and  especially  for  the  general 
practitioner,  since  he  generally  sees  these  cases  first,  and  his 
actions  and  counsels  generally  determine  the  issue.  Unless 
the  injury  is  an  absolutely  superficial  one,  he  should  not  under- 
take to  give  more  than  a  doubtful  prognosis.  He  should  at 
once  apply  antiseptic  measures,  as  stated  above,  and  should 
prepare  the  patient  for  what  may  prove  to  be  the  only  re- 
source, not  only  to  save  him  great  suflering  from  the  injured 
eyeball,  but  also  to  avert  imminent  danger  of  total  bHndness 
from  the  loss  of  its  fellow,  namely:  The  removal  of  the  in- 
jured eyeball  by  enucleation.  The  patient  will  then  probably 
more  readily  yield  to  the  dire  necessity,  or  if  he  does  not,  and 
finally  becomes  blind,  the  physician  has  at  least  done  his 
duty. 

The  question,  whether  an  injured  eyeball  is  to  be  removed 
or  not,  depends  not  only  on  the  nature  and  extent  of  the  inju- 
ry, but  also  on  the  fact  whether  a  foreign  body  remains  within 
the  eyeball  or  not.  Of  this  latter  point  the  patient  has  usually 
no  means  of  forming  a  correct  judgment,  and  the  physician 
should  not  rely  on  his  statements,  unless  he  can  satisfy  himself 
that  the  instrument  which  has  caused  the  injury  cannot  possi- 
bly have  left  a  particle  within  the  eyeball.  If  there  is  no 
doubt  remaining  as  to    the  necessity   of  removing  the  injured 


INJURIES  OF  THE  EYEBALL,  217 

eye,  the  sooner  it  is  done  the  better  for  the  patient.  The 
operation  affords  immediate  relief  from  the  excruciating  and 
continuous  pain,  and  the  quiet  and  speedy  healing,  which  is 
the  rule  after  enucleation,  will  enable  the  patient  to  resume  his 
work  after  a  very  short  period. 

When  in  any  given  case  there  is  well-founded  doubt,  al- 
though still  a  probability  that  enucleation  will  become  neces- 
sary later  on,  our  action  should  depend  largely  on  the  patient's 
position  in  life,  and  on  the  possibility  of  watching  the  eyes 
carefully,  and  doing  what  is  necessary  at  the  first  indication. 

Instead  of  enucleation,  evisceration,  scraping  of  all  the  con- 
tents out  of  the  scleral  shell,  has  been  introduced,  as  giving  a 
better  stump  for  the  wearing  of  an  artificial  eye.  The  opera- 
tion is  followed  by  a  slow  and  painful  healing  process.  It  is, 
moreover,  less  certain  that  all  septic  infective  material  may  be 
removed  by  means  of  it,  than  by  enucleation.  To  improve 
the  stump  still  more,  an  artificial  vitreous  of  glass  (Mules)  may 
be  inserted  into  the  scleral  cavity  and  be  allowed  to  become 
encapsulated.  When  there  is  only  a  question  of  good  looks, 
this  operation  may  be  in  place. 

Section  or  removal  of  a  piece  of  the  the  optic  nerve  and  the 
ciliary  nerves  around  its  entrance  (optico-ciliary  neurotomy  or 
neurectomy)  have  also  their  advocates.  In  view  of  a  possible 
sympathetic  ophthalmia  they  are  not  as  reliable  as  enucleation. 

From  the  great  frequency  and  destructive  nature  of  injuries 
of  the  eyeball  incident  to  certain  dangerous  trades,  the  use  of 
protective  glasses  cannot  be  too  strongly  urged  upon  the 
workmen,  whose  occupation  exposes  them  daily  to  such  perils. 
Such  protective  glasses  are  best  made  of  mica,  and  in  Europe, 
where  they  are  extensively  used,  they  have  been  the  means  of 
saving  many  a  workman  from  blindness  and  many  a  family 
from  destitution.  It  is  greatly  to  be  deplored  that  American 
workmen  cannot  be  persuaded  to  use  them. 

§117.  Injuries  to  the  eyeball  by  blunt  forces  may  cause  rup- 
ture of  the  sphincter  edge  of  the  iris,  iridodialysis,  isolated 
rupture  of  the  choroid  and  probably,  also,  of  the  ciliary  body. 
These  injuries  may  be  accompanied  by  considerable  haemor- 
rhage.    If  the   haemorrhage  concerns  the   anterior   chamber 


218 


OPHTHALMOLOG  Y. 


only,  it  is  called  hyphcema,  if  all  the  cavities  of  the  eye  are 
filled  with  blood  it  is  called  hcemophthalmus.  Blunt  force  may 
furthermore  cause  the  iris  to  be  tilted  backwards  and  remain 
in  this  position  when  it  will  look  as  if  part  of  the  iris  had  dis- 
appeared.    (See  Fig.  91).     This  is  particularly  observed  when 


Fig.  91. — Tilting  backwards  of  the  iris  after  contusion  of  the  eyeball. 

the  force  has  struck  the  cornea  directly  from  in  front,  as  by  a 
cork  flying  from  a  soda-water  or  champagne  bottle.  Some- 
times a  partial  paralysis  of  the  sphincter,  probably  due  to  the 
unbloody  tearing  of  muscular  fibres  will  render  the  pupil  oval. 


F)G.  92. — Dislocation  of  the  crystalline  lens  under  the  conjunctiva  by  an  injury 
which  ruptured  the  sclerotic. 

Subluxation  and  dislocation  of  the  crystalline  lens  are  often 
the  result  of  blunt  injuries.  In  rare  cases  the  cornea  or  scler- 
otic is  ruptured.  In  these  cases  the  lens  may  at  the  same 
time  be  forced  out  of  the  eyeball,  and  it  sometimes  remains 
lying  under  the  conjunctiva.     (See  Fig.  92). 


CHAPTER    XIX.— SYMPATHETIC    OPHTHALMIA. 

§ii8.  Sympathetic  ophthalmia  is  the  collective  name  given 
to  all  affections  which  are  brought  about  in  an  eye  by  certain 
diseased  conditions  in  its  fellow,  when  these,  and  these  alone, 
are  the  cause  of  the  affection  in  the  second  eye. 

If,  for  instance,  a  patient  suffers  from  idiopathic  iritis  in  one 
eye,  and  his  other  eye  is  attacked  in  the  same  way  soon  after, 
we  do  not  call  this  a  sympathetic  iritis,  because  the  second  eye 
becomes  affected  through  the  same  constitutional  diathesis 
which  has  led  to  the  iritis  in  the  first  eye. 

By  far  the  greater  number  of  cases  of  sympathetic  ophthal- 
mia, if  not  all,  are  due  to  inflammatory  processes  induced  in  the 
first  affected  eye  by  an  injury,  with  or  without  the  continuing 
presence  of  a  foreign  body  within  the  eyeball.  Experience 
has  shown  that  chronic  cyclitis  is  especially  apt  to  be  devel- 
oped in  such  an  eye,  causing  often  a  similar  sympathetic 
trouble  in  the  other  eye.  From  this  fact  it  has  been  thought 
that  a  direct  transmission  of  the  inflammatory  process  takes 
place  along  the  ciliary  nerves.  This  theory  is  open  to  certain 
serious  objections,  and  we  have,  moreover,  other  and  more  di- 
rect channels  for  the  transmission  of  an  inflammation  from  one 
eye  to  the  other  in  the  optic  nerve  with  its  sheaths  and  other 
lymph- channels.  Pathological  anatomy  and  experiments,  as 
well  as  clinical  observations,  point  decidedly  to  these  channels 
as  being  the  most  important  ones  in  the  transmission  of  the 
disease. 

Since  the  influence  of  septic  bacteria  upon  the  causation 
and  transmission  of  disease  has  become  known  and  carefully 
studied,  the  character  of  true  sympathetic  ophthalmia  (not 
sympathetic  irritation)  as  a  transmitted  septic  infection  has  all 
but  been  established  \_Leber,  Deutschmanti]  (ophthalmia  migra- 
torid).  Although  a  number  of  observers  have  been  unable  to 
find  the  bacteria  in  eyes  which  had  produced  sympathetic  oph- 
thalmia (among  them    myself),  this    is  no  proof  that  Deutsch- 

—219— 


2ii0  OPHTHALMOLOGY, 

mann's  views  are  incorrect.  Whether  the  channels  by  which 
the  migration  of  the  septic  bacteria  takes  place  from  one  eye 
to  the  other  are  to  be  found  in  the  optic  nerve  and  its  pia  ma- 
ter sheath  alone  {Knies)^  or  also  in  lymph-channels  which  leave 
the  optic  nerve  with  the  central  bloodvessels  and  go  through 
the  orbit  into  the  cranial  cavity  {Gifford),  is  still  a  mooted 
question. 

The  time  at  which  sympathetic  affection  most  frequently  oc- 
curs is  in  from  4  to  6  weeks  after  the  injury  has  been  inflicted  on 
the  fellow-eye.  In  a  large  number  of  cases,  however,  such  an 
injury  may  have  preceded  the  occurrence  of  the  sympathetic 
affection  by  many  months,  and  even  by  years.  In  rare  cases 
a  few  days  only  seem  to  have  intervened  between  the  affection 
of  the  two  eyes. 

As  an  eye  once  affected  by  sympathetic  ophthalmia  is,  as  a 
rule,  ruined,  and  the  patient  is  thus  in  most  cases  rendered  ut- 
terly and  hopelessly  blind,  this  subject  is  one  of  the  most  im- 
portant in  ophthalmic  practice,  and  the  physician  cannot  be  too 
deeply  impressed  with  its  importance.  In  most  cases  the  duty 
will  devolve  upon  him  to  forestall  the  fearful  results,  and  to 
tell  the  patient  what  probably  will  be  his  only  safeguard  against 
utter  blindness.  If  the  physician  does  not  recognize  his  duty 
but  through  lack  of  judgment,  or  for  any  other  reason  encour- 
ages the  patient  to  reject  the  one  effective  remedy,  the  enu- 
cleation of  an  injured  eyeball,  or  of  an  eyeball  which,  for 
other  reasons,  is  likely  to  produce  sympathetic  inflammation, 
the  blame  will  rightfully  fall  on  his  shoulders. 

The  eyes,  which  are  most  apt  to  give  rise  to  sympathetic 
troubles  are,  as  just  stated,  especially  injured  eyes,  and  among 
these  again,  especially  eyes  in  which  the  injury  has  been  in 
the  ciliary  region,  or  in  which  there  has  been  a  prolapse  of  the 
iris,  or  the  ciliary  body,  or  of  the  choroid  and  retina,  and  those 
eyeballs  within  which  a  foreign  body  has  become  lodged.  Ec- 
tatic  corneal  scars,  staphyloma  in  all  its  forms,  plastic  iridocy- 
clitis, and  iridochoroiditis,  and  anterior  phthisis  of  the  eyeball 
may  also  cause  sympathetic  trouble.  Furthermore,  operations 
on  the  eye,  and  especially  cataract  extractions,  when  followed 
by  septic  inflammation,  may  be  the  source  of  a  sympathetic 
inflammation. 


SYMPATHETIC   OPHTHALMIA.  221 

The  primarily  affected  eyeball  need  not  be  absolutely  de- 
stroyed to  become  a  source  of  danger;  it  may  even  be  a  com- 
paratively useful  organ,  and  yet  be  so  affected  as  possibly  to 
cause  a  sympathetic  affection  in  the  other  eye.  In  most  cases, 
however,  vision  in  the  first  affected  eye  is  reduced  to  the 
mere  perception  of  light,  or  is  even  altogether  abolished  be- 
fore such  an  eye  becomes  dangerous  to  its  fellow. 

§119.  Sympathetic  ophthalmia  may  appear  clinically  in 
different  forms,  which  it  is  especially  necessary  to  recognize 
in  the  initial  stage. 

The  lightest  form  of  sympathetic  ophthalmia,  and  usually 
the  forerunner  of  the  more  serious  forms  in  which  organic 
changes  take  place,  is  that  which  is  conventionally  termed 
sympathetic  irritation. 

An  eye  suffering  from  sympathetic  irritation  shows  no  or- 
ganic changes;  however,  it  can  not  bear  the  light  well.  It  tires 
easily,  especially  in  reading  or  similar  occupations;  moving 
the  books  farther  off  may  give  momentary  relief  (weakened  ac- 
commodation). Soon  even  the  slightest  application  of  the  eye 
to  any  work  causes  lachrymation  and  redness,  and  the  attend- 
ant pain  in  the  surrounding  regions  makes  work  utterly  im- 
possible. Sight  may  be  at  times  slightly  obscured,  or  the  pa- 
tient may  see  shining  spots  and  flashes  of  light  {photopsia). 

In  this  stage  of  the  disease,  in  which  no  anatomical  lesions 
have  apparently  as  yet  taken  place  in  the  tissues  of  the  secon- 
darily affected  eyeball,  the  enucleation  of  the  eye  which  is  the 
cause  of  the  trouble,  will  generally  be  followed  by  a  speedy 
recovery.  We  should,  therefore,  be  very  careful  to  instruct  a 
patient,  who  is  the  unlucky  possessor  of  an  injured  eye,  or  an 
eye  that  may  at  some  time  cause  sympathetic  inflammation, 
that  such  symptoms  as  have  been  enumerated,  however  trivial 
he  may  consider  them,  must  not  be  overlooked,  but  must  be 
promptly  reported.  He  must,  in  fact,  be  made  so  thoroughly 
aware  of  the  danger  to  his  other  eye  that  he  will  be  startled 
at  even  the  shghtest  unusual  symptom  in  his  good  eye.  All 
the  symptoms  which  together  we  call  sympathetic  irritation 
are  to  be  explained  as  caused  by  reflex-neurosis  and  are  trans- 
mitted by  the  sensory,  motor  and  sympathetic  fibres  by  way 
of  the  ciliary  nerves. 


222  OPHTHALMOLOG  V. 

§120.  In  some  cases  these  functional  symptoms  of  sympa- 
thetic irritation  have  already  become  complicated  by  organic 
changes,  and  sympathetic  neuritis  or  neuro-retinitis  has  actually 
set  in  when  we  first  examine  the  eye.  Even,  then,  if  no  fur- 
ther changes  have  taken  place,  enucleation  of  the  first  affected 
eyeball  may  bring  about  a  perfect  cure.  Whether  such  a 
neuritis  is  a  primary  affection  or  whether  it  is  due  to  a  begin- 
ning inflammation  of  the  uveal  trace  is  not  certain. 

§121.  More  frequently,  however,  we  observe  that  the  pa- 
tient is  suffering  from  sympathetic  iritis,  which  may  be  either 
of  a  serous  or  a  plastic  type.  Serous  iritis  seems  to  give  a 
comparatively  good  prognosis,  but  plastic  iritis,  which  very 
soon  develops  into  plastic  irido-cyclitis,  as  a  rule,  leaves  noth- 
ing to  be  hoped  for.  In  a  few  reported  cases  in  which  enucle- 
ation has  been  performed  as  soon  as  the  first  symptoms  of 
iritis  have  been  detected,  a  cure  has  even  then  been  effected, 
but  in  most  cases  it  is  useless,  and  it  may  even  be  injurious  to 
enucleate  at  this  period. 

Gradually  the  sympathetic  iridocyclitis  develops  into  an 
irido-choroiditis,  and  the  contraction  of  the  plastic  membranes 
leads  to  shrinkage  of  the  whole  eyeball  with  detachment  of 
the  retina  and  softening  of  the  eye.  Every  chance  of  help  is 
gone  in  this  stage. 

The  process  of  sympathetic  ophthalmia  is,  as  a  rule,  very 
gradual;  there  may  be  times  of  apparent  freedom  from  inflam- 
mation, or,  at  best,  partial  remission  of  the  inflammation;  but 
soon  a  new  exacerbation  will  take  place,  and  the  destructive 
process  goes  on.  In  a  few  cases  the  disease  stops  before  the 
eye  is  utterly  ruined,  and  then  a  judicious  operation  may  ulti- 
mately give  some  sight.  But  no  operation  on  an  eye,  made 
useless  by  sympathetic  ophthalmia,  should  under  any  circum- 
stances be  attempted,  until  all  signs  of  inflammation  or  even 
of  irritability  are  gone,  or  better  yet,  have  been  gone  for  some 
time.  If,  in  such  a  case,  the  perception  of  light  and  the  pro- 
jection are  good,  and  the  intraocular  tension  is  but  slightly,  or 
not  at  all  reduced,  an  operation  (usually  iridectomy  or  iridot- 
omy,  or  one  of  these  combined  with  extraction  of  the  frequent- 
ly cataractous  crystalline  lens),  may  be   undertaken  with    the 


SYMPATHETIC   OPHTHALMIA,  223 

hope  of  restoring  some  degree  of  vision.  Any  attempt  at 
operation  at  an  earlier  period  will  be  punished  by  a  new  exac- 
erbation of  the  disease,  or  at  best  will  prove  useless,  as  even 
large  openings  made  in  the  iris  and  the  pathological  newform- 
ations  will  be  in  a  very  short  time  closed  again  by  inflamma- 
tory products. 

§122.  While  the  inflammation  is  in  progress  subconjuncti- 
val injections  of  mercury,  mercurial  inunctions,  or  mercury 
given  internally,  may  prove  of  value;  pilocarpine  may  per- 
haps, also,  be  of  service.  Untiring  eflbrts  are  sometimes  even 
at  such  a  period  crowned  with  a  partial  success. 

Obstinate  keratitis  or  scleritis  has  in  some  cases  been  caused 
by  the  presence  of  an  injured  or  shrunken  eyeball,  and  has 
been  cured  only  after  the  enucleation  of  the  offending  organ, 
and  is,  therefore,  described  as  sympathetic  keratitis  or  scleritis. 

It  has  been  stated  above  that  it  has  been  recommended  to 
substitute  for  enucleation  the  operation  of  division  of  the  cil- 
iary nerves  and  the  optic  nerve  close  to  the  posterior  surface 
of  the  eyeball  (optic o-ciliary  neurotomy),  or  the  removal  of  a 
piece  of  these  nerves  (pptico-ciliary  neurectomy);  also  eviscera- 
tion of  the  eyeball.  (See  Chapter  XVIII).  Enucleation, 
however,  still  remains  the  only  really  trustworthy  remedy,  and 
when  it  is  performed  in  time  and  before  any  sign  of  sympa- 
thetic ophthalmia  has  appeared,  the  only  safe  prophylactic 
measure. 

§123.  The  wearing  of  an  artificial  eye  will,  in  a  great  meas- 
ure, do  away  with  the  disfigurement  caused  by  the  enucleation 
as  it  not  only  appears  very  much  like  a  living  eye,  but  can 
even  be  moved  to  a  certain  degree  in  all  directions.  This  is 
due  to  the  fact  that  the  external  muscles  of  the  enucleated 
eyeball  grow  together  with  the  orbital  tissue  and  the  conjunc- 
tiva. The  shell  of  the  artificial  eye,  resting  on  the  orbital  fat 
covered  with  conjunctiva,  is  thus  moved  whenever  one  of  these 
muscles  contracts. 

The  wearing  of  an  artificial  eye  is,  however,  a  source  of  ex- 
pense and  often  of  annoyance.  Discharges  of  the  conjunctiva 
will  accumulate  behind  the  artificial  eye  and  dry  on  its  surface, 


224  OPHTHALMOLOGY. 

and  in  order  to  clean  it  and  wash  out  the  conjunctival  sack,  it 
must  frequently  be  removed.  In  cold  weather  artificial  eyes 
are  apt  to  break  within  the  orbit.  The  expense  and  annoy- 
ance, therefore,  make  it  desirable  in  certain  cases  to  close  the 
palpebral  fissure  after  removing  the  cilia-bearing  edges  and, 
perhaps,  also  the  tarsal  tissue  and  conjunctival  sack. 


CHAPTER     XX— ERRORS    OF    REFRACTION    AND 
ACCOMMODATION. 

§124.  Every  eye,  which  is  so  constructed,  that,  while  it  is 
perfectly  at  rest,  parallel  rays  entering  through  its  cornea  are 
united  in  a  point  {focus)  on  its  retina^  is  called  an  emmetropic 
eye.    (See  Fig.  93). 


Fig.  93. — Emmetropic  eye.     Parallel  rays  passing  through  the  refractive  media  of 
the  emmetropic  eye,  when  it  is  at  rest,  are  focussed  on  the  retina. 

By  parallel  rays  we  mean,  in  practice,  such  rays  as  reach  the 
eye  from  any  distant  object,  and  for  most  purposes  we  may, 
without  material  error,  consider  rays  as  parallel  when  the  ob- 
ject from  which  they  emanate  is  at  any  distance  greater  than 
twenty  feet  from  the  eye.  The  emmetropic  eye  sees,  there- 
fore, any  distant  object  towards  which  it  is  directed  distinctly 
and  without  effort. 

Every  eye  which  is  not  so  constructed  that,  when  in  a  state 
of  rest,  parallel  rays  are  focussed  on  its  retina,  is  called  an 
ametropic  eye. 

An  eye  in  which  the  retina  lies  in  front  of  the  focus  for  par- 
allel rays,  and  which  therefore  cannot,  in  a  state  of  rest,  see 
even  distant  objects  distinctly,  is  called  a  hypermetropic  eye 
(over-sighted  eye).     (See  Fig.  94). 

Every  eye  whose  retina  lies  behind  the  focus  for  such  parall- 

—225— 


226 


OPHTHALMOL  OGY. 


el  rays,  and  which    therefore    sees    near   objects    distinctly,  is 
called'a  myopic  eye  (near-sighted eye).    (See  Fig.  95). 


Fig.  94. — The  hypermetropic  eye  is  shorter  than  the  emmetropic  one  and  parallel 
rays  are  focussed  in  consequence  behind  the  retina,  when  the  eye  is  at  rest. 

In  other  words,  when  perfectly  at  rest,  the  emmetropic  eye  is 
focussed  for  parallel  rays,  the  hypermetropic  eye  is  focussed  for 
convergent  rays,  and  the  myopic  eye  is  focussed  for  divergent 
rays. 


Fig.  95. — The  myopic  eye  is  an  elongated  eye.     Parallel  rays  passing  through  its 
refractive  media  are  focussed  before  having  reached  the  retina. 

The  point  for  which  an  eye  is  focussed,  when  in  a  state  of 
rest,  is  called  the  far-point  of  that  eye.  In  the  case  of  the 
enametropic  and  hypermetropic  eye  the  far-point  is  at  an  indef- 
ite  distance;  in  the  myopic  eye  the  far-point  is  at  a  finite,  and 
often  a  very  short  distance  from  the  eye. 

For  the  determination  of  the  acuteness  of  vision  in  any 
eye  (see  Chapter  II),  we  make  use  of  test-types  constructed 
after  a  certain  principle.     It  has  been  found  that  an    object,  in 


ERR ORS  OF  REFRA C TION  AND  AC C OMMO DA TION.         227 

order  to  be  distinctly  perceived  by  the  human  eye,  must  be 
seen  under  a  visual  angle  of  at  least  i  minute.  The  letters, 
therefore,  are  arranged  in  such  a  manner  that  at  a  certain  given 
distance  each  limb  of  a  letter  is  seen  under  this  visual  angle, 
and  the  whole  letter  under  an  angle  of  5  minutes.  The  letters 
are  numbered  to  correspond  with  the  distance  in  feet,  at  which 
each  letter  should  be  seen  under  this  angle  by  the  normal  eye. 
Thus  the  letters  which   should  be  seen  at  20  feet  are  marked 


T  P 


Fig.  96. — Snellen's  test-types,  seen  by  ah  eye  with  normal  acuity  of  vision  at  two 
hundred,  one  hundred,  and  twenty  feet  respectively. 

XX;  at  70  feet  LXX,  and  so  on.  (See  Fig.  96).  If  at  20  feet 
distance  an  eye  can  read,  for  instance,  only  the  letters  which 
a  normal  eye  ought  to  read  at  70  feet,  we  express  the  visual 
acuteness  (V)  of  that  eye  by  the  fraction  '^"/lxx-     (See  Chapter 

II). 

The  same  test-types   are  used  for  the   determination  of  the 
refractive  condition  of  the  eyes.     If  an  otherwise  healthy  eye 


228  OPHTHALMOL  OGY. 

can  see  the  letters,  which  are  seen  by  the  normal  eye  distinctly 
at  20  feet  at  that  distance,  it  is  emmetropic,  or  it  may,  as  we 
shall  see  later  on,  be  moderately  hypermetropic.  If  such  an 
eye  can  read  these  letters  as  well  or  better,  when  a  convex 
lens  is  held  before  it,  it  is  hypermetropic.  If  a  concave  lens 
is  required  to  bring  vision  up  to  ^7xx,  the  eye  is  myopic. 

Another  form  of  ametropia  is  caused  by  an  asymmetry 
of  curvature  in  the  different  meridians  of  the  cornea,  or 
of  the  crystalline  lens.  Such  an  eye  sees  everything 
blurred  and  indistinct,  and,  although,  perhaps,  improved  by 
convex  or  concave  lenses,  it  does  not  by  their  use  alone  come 
up  to  the  standard  of  the  normal  eye.  We  shall  later  on  give 
further  details  of  this  condition,  which  is  called  astigmatism, 
because  these  eyes  cannot  reunite  the  rays  which  emanate  from 
any  given  point  of  the  object  upon  any  local  point  {stigma) 
within  the  eye. 

We  have  seen  that  the  eye,  when  at  rest,  is  focussed  for  its 
far-point,  which  for  the  normal  eye  lies  at  an  infinite  distance, 
but  the  eye  has  also  the  power  of  seeing  small,  near  objects 
with  perfect  distinction,  or,  in  other  words,  it  posseses  a  power 
of  adjustment  by  which  it  can  focus  upon  its  retina  either 
pai^llel  or  divergent  rays.  This  necessarily  implies  that 
there  is  a  faculty  residing  in  the  eye  by  which  it  is  enabled,  at 
will  to  increase  its  refractive  power  to  meet  the  requirements 
of  near  vision.  This  faculty  lies  in  organs  within  the  eyeball, 
and  is  called  accommodation.  It  may  be  expressed  as  equiva- 
lent to  a  convex  lens  of  such  power  as  would  suffice  to  render 
the  divergent  rays  coming  from  the  near  object  parallel,  as  if 
they  came  from  a  distant  object. 

The  nearest  point  at  which  a  small  object  can  be  seen  dis- 
tinctly by  an  eye,  we  call  its  near-point.  The  difference  be- 
tween the  near  and  the  far-point  gives  us  the  range  of  accom- 
modation of  an  eye. 

The  accommodative  power  is,  however,  not  the  same  through- 
out life.  It  diminishes  with  advancing  age,  and  after  the  age 
of  45  or  50  years  it  is  reduced  to  a  small  fraction.  In  conse- 
quence of  this  loss  of  accommodative  power,  the  near-point 
gradually  recedes  farther  and  farther  from  the  eye,  and  thus  is 
approximated  more  and  more  nearly  to  the  far-point. 


ERRORS  OF  REFRACTION  AND  ACCOMMODATION,         229 

In  every  visual  act  not  only  must  each  eye  be  accommodated 
singly  for  the  distance  of  the  object,  but  the  axes  of  the  two 
eyes  must  be  made  to  converge  accurately  upon  the  same 
point  of  the  object  in  order  to  form  identical  images  upon  the 
maculae  luteae  of  the  two  retinae.  Accommodation  is,  therefore, 
intimately  associated  with  convergence,  and  whenever  the  one 
adjustment  is  called  into  activity,  the  other  is  performed  at 
the  same  time,  even  when  through  some  abnormal  condition 
such  an  association  of  the  two  adjustments  does  not  contrib- 
ute to  more  perfect  vision. 

The  organ  by  which  the  act  of  adjustment  for  near  objects 
is  performed,  are  the  ciliary  muscle  and  the  crystalline  lens, 
Helmholtz  has  explained  the  action  in  the  following  way: 
When  the  ciliary  muscle,  which  forms  a  ring  in  which  the 
crystalline  lens  is  held  by  the  suspensory  ligament  {^zonule  of 
Zinn)  is  contracted,  this  ligament  becomes  relaxed,  and  the 
crystalline  lens,  by  its  inherent  elasticity,  assumes  a  more 
nearly  spherical  shape,  and  its  refractive  power  is  correspond- 
ingly increased,  as  if  a  meniscus  had  been  added  to  it. 

When  we  observe  an  eye  during^  the  act  of  accommodation, 
we  see  that  the  pupil  becomes  smaller,  and  that  the  pupillary 
edge  of  the  iris  is  slightly  moved  forwards.  Accurate  obser- 
vation has  shown  that  the  increased  convexity  of  the  crystall- 
ine lens  during  accommodation  is  due  mainly  to  a  change  in 
the  form  of  its  anterior  surface. 

§125.  Hypermetropia  (oversight  or  far-sight)  ^xxsts,  diS  has 
been  stated,  when  the  eye  in  a  state  of  rest  is  focussed  for 
convergent  rays,  and  parallel  rays  entering  the  eye  are  refract- 
ed towards  a  point  lying  behind  its  retina.  In  consequence  of 
this  condition  the  retina  of  such  an  eye  receives  only  disper- 
sion circles,  and  the  images  of  distant  objects,  and  still  more 
of  near  objects,  must  be  indistinct.  This,  as  has  been  stated, 
can  be  remedied  by  convex  glasses,  and  the  convex  glass  which 
will  allow  a  hypermeti:opic  eye,  when  perfectly  at  rest,  to 
unite  parallel  rays  upon  its  retina  gives  us  the  degree  of  its 
hypermetropia. 

In  hypermetropia,  if  no  glass  is  worn,  the  deficiency  in  re- 
fractive power  is  ordinarily,  at  least  for  distant  vision,  reme- 


230  OPHTHALMOLOCk. 

died  by  the  exercise  of  the  accommodation,  and  in  low  degrees 
of  hypermetropia,  this  may  suffice  for  a  time,  even  for  near 
objects.  Low  degrees  of  hypermetropia  may  thus  remain  un- 
known to  the  patient  for  years,  or  until  his  accommodative  ap- 
paratus can  no  longer  do  its  work  effectively.  This  continu- 
ous strain  of  the  accommodative  apparatus  causes,  moreover, 
a  permanent  contraction  of  the  ciliary  muscle,  so  that  it  can 
no  longer  be  perfectly  relaxed  at  will. 

In  such  a  case,  when  testing  the  refraction,  we  may  meet 
with  an  eye  with  an  apparently  normal  acuteness  of  vision, 
although  it  is  hypermetropic.  That,  what  appears  to  be  an 
emmetropic  eye  is  in  reality  a  hypermetropic  one,  is  recogniz- 
ed by  the  fact  that  a  weak  convex  lens  held  before  it,  does  not 
diminish  the  acuteness  of  vision,  and  may  even  improve  it. 
The  amount  of  hypermetropia  which  is  thus  disguised  by  the 
help  of  accommodation  is  called  latent  hypermetropia.  Even, 
when  the  examination  of  an  eye  plainly  reveals  a  certain  de- 
gree of  hypermetropia,  the  correction  of  which  by  means  of  a 
convex  lens,  may  give  normal  visual  acuteness,  an  additional 
qnantity  of  hypermetropia  remains  latent.  The  former  is 
called  manifest  hypermetropia.  In  order  then  to  find  out  the 
total  hypermetropia  we  must  get  rid  of  all  accommodative  ef- 
fort on  the  part  of  the  patient.  This  is  best  done  by  paralyzing 
the  accommodation  by  means  of  the  instillation  of  some  drops 
of  a  one  per  cent,  solution  of  the  sulphate  of  atropia,  or  one  of 
the  more  recent  mydriatics.  The  convex  lens  which  now  suc- 
ceeds in  giving  the  patient  normal  acuteness  of  vision  gives  us 
the  exact  degree  of  his  total  hypermetropia.  The  paralysis 
of  the  accommodation  by  means  of  atropia  renders  the  eye 
unfit  for  any,  or  at  least  continued,  near-work  for  from  lo  to  12 
days,  and  sometimes  even  longer.  To  obviate  this  the  hydro- 
bromate  of  homatropia  has  been  introduced  as  a  substitute, 
as  its  action  disappears  in  about  thirty  hours.  After  having 
used  this  drug  freely  for  several  years  in  solution  and  in  the 
form  of  Wood's  disks  with  cocaine  ^dded,  I  am  satisfied  that 
in  a  large  number  of  cases  its  paralyzing  action  certainly  is 
strong  enough  to  replace  that  of  atropine;  but  in  a  quite  re- 
spectable minority  of  the  cases  it  is  unable  to  reveal  the  total 
amount  of  hypermetropia.     Where    time   and    other   circum- 


ERRORS  OF  REFRACTJON  AND  ACCOMMODATION.         231 

stances  allow  it,  atropia  should  be  used.  When  the  patient 
cannot  give  the  time,  homatropine  may  take  its  place  with  re- 
serve. 

Some  patients  whose  accommodative  apparatus  is  strong 
enough  to  permanently  overcome  without  discomfort  a  certain 
degree  of  hypermetropia,  may  never  care  to  use  correcting 
glasses,  nor  really  feel  the  need  of  them  until  presbyopia  de- 
velops. Others  in  whom  there  is  perhaps  a  lower  degree  of 
strength  of  accommodative  power  than  should  even  be  ex- 
pected in  a  normal  eye,  will  require  the  correction  by  glasses 
of  so  small  a  degree  of  hypermetropia,  that  most  individuals 
would  never  become  conscious  of  its  existence. 

Theoretically,  the  glasses  which  correspond  to  the  total  de- 
gree of  hypermetropia  ought  to  be  the  best,  or  rather  the  most 
useful  ones  to  the  patient,  since  they  will  remove  all  undue 
strain  from  his  accommodative  apparatus.  We  find,  however, 
generally  that  the  old  habit  of  accommodating  more  than  nec- 
essary, comes  back  in  some  measure,  when  the  effect  of  the 
paralyzing  drug  has  passed  off.  The  patients,  therefore,  often 
refuse  these  glasses  at  first,  and  are  better  satisfied  with  a  num- 
ber that  lies  between  the  degree  of  their  manifest  and  of  their 
total  hypermetropia.  Long  continued  paralysis  of  the  accom- 
modation may  eventually  do  away  with  this  habitual  excessive 
strain  of  the  accommodative  apparatus,  but  it  is  generally  bet- 
ter to  begin  by  giving  glasses  of  such  strength  as  the  patient 
can  use  with  comfort,  and  to  change  them  later  on  for  strong- 
er ones. 

The  question  has  even  been  raised  whether  in  children  it  is 
really  best  to  correct  a  moderate  and  even  a  medium  degree 
of  hypermetropia  at  all,  and  it  has  been  pointed  out  that  the 
accommodative  strain  during  the  years  of  development  will 
help  to  bring  about  a  natural  cure  of  the  hypermetropia  by  the 
stretching  of  the  eyeball  during  its  growth  [Carter).  In  this 
manner  a  hypermetropic  eye  may  become  at  some  stage  emme- 
tropic. Such  an  occurrence  is,  however,  just  as  apt  to  be  fol- 
lowed by  more  stretching  than  is  wished  for  and  by  such  an 
increase  in  refraction  that  the  eye  becomes  myopic.  The  gain 
under  these  circumstances  would  be    a  very  questionable  one. 

Hypermetropic  patients  should,  as  a  rule,  wear  their  glasses 


232  OPHTHALMOL  OGY. 

always,  except  when  their  hypermetropia  is  of  a  very  moder- 
ate grade,  and  their  far-vision  is  comparatively  good.  In  ad- 
vanced years,  when  presbyopia  is  added  to  the  hypermetropia, 
different  glasses  for  distance  and  for  reading  must  be  used. 

§126.  The  most  frequent  and  characteristic  symptom  of  hy- 
permetropia is  accommodative  asthenopia.  The  patient  may 
have  perfect  acuteness  of  vision,  but,  when  doing  near  work, 
such  as  reading,  writing,  sewing,  etc.,  his  sight  which  at  the 
beginning  was  good,  becomes  indistinct,  the  letters  run  into 
each  other,  and  the  eyes  feel  tired.  By  instinctively  closing 
the  eyes,  and  resting  them  for  a  moment,  sight  appears  im- 
proved again;  but  soon  this  short  rest  fails  to  give  relief.  Later 
on,  pain  in  the  forehead,  injection  of  the  conjunctival  blood- 
vessels and  lachrymation  are  added  to  the  former  symptoms, 
and  the  work  must  be  laid  aside. 

These  symptoms  are  usually  more  pronounced  when  the 
near  work  is  done  by  artificial  light.  The  patients  tell  us  some- 
times that  the  symptoms  have  taken  their  origin  from  some  se- 
vere illness,  and  in  fact  any  weakening  influence  will  suffice  to 
bring  them  to  light,  by  rendering  the  strain  of  the  accommo- 
dative apparatus  impossible. 

Occasionally  the  patients  are  unable  to  read  at  all,  and  suffer 
from  almost  constant  headache,  and  not  infrequently  we  meet 
with  a  case  in  which  the  patient  has  been  treated  for  years  for 
some  dark  and  hidden  nervous  trouble,  and  has  been  subjected 
to  all  sorts  of  needless  deprivations  and  even  operations,  where 
the  use  of  the  proper  glasses  will  suffice  at  once  to  remove 
all  distressing  symptoms. 

Hypermetropic  children  often  hold  their  books  close  to  the 
eye,  as  if  they  were  very  short-sighted,  and  thus  they  strain 
their  accommodation  even  more  than  would  appear  to  be  nec- 
essary for  clear  vision.  This  is  probably  due  to  the  increase 
in  size  of  the  retinal  image  thus  gained,  and  may  grow  with 
them  into  a  confirmed  habit.  The  fact,  however,  that  such 
children  can  distinguish  small  distant  objects  clearly,  such  as 
birds,  telegraph  wires,  etc.,  will  at  once  reveal  the  fact  that 
they  are  not  short-sighted.  In  these  cases  a  spasm  of  the  ac- 
commodative apparatus  takes  place,  in  consequence  of  which 


ERR  ORS  OF  REFRA  C  TION  AND  A  C  COM  MOD  A  TION  233 

the  eye  appears  to  be  near-sighted  and  will  apparently  prefer 
correction  by  a  concave  glass,  until  the  instillation  of  atropia 
and  consequent  paralysis  of  the  ciliary  muscle  will  show  that 
the  eye  is  really  a  hypermetropic  one. 

It  has  been  stated  above  that  the  functions  of  accommodation 
and  convergence  are  closely  connected,  and  it  is  only  after 
long  practice  that  we  can  learn  to  accommodate  without  cori- 
verging,  or  vice  versa.  The  hypermetropic  patient,  in  order  to 
see  small  objects  distinctly,  must  exert  more  accommodative 
effort  than  the  emmetrope.  He  will,  therefore,  also  instinctive- 
ly converge  his  eyes  more,  and  thus  it  may  easily  happen  that 
he  converges  too  much,  so  that  converge?it  strabismus  may  be 
developed.  In  other  words,  the  hypermetrope  will,  while 
using  his  accommodation  in  reading,  converge  his  eyes  more 
than  is  necessary  for  the  distance  of  the  object.  He  thus 
loses,  of  course,  the  benefit  of  binocular  vision,  and  also  sees 
the  object  doubled.  As  this  diplopia  is  a  source  of  confusion, 
he  gets  rid  of  it  by  turning  one  eye  still  further  inwards,  and 
works  only  with  the  other  one.  Thus  the  abnormal  adduction 
is  thrown  entirely  into  one  of  the  eyes,  and  the  well-known 
picture  of  strabismus  convergens  (cross-eye)  is  developed. 

Patients  with  a  very  high  degree  of  hypermetropia  do  not 
gain  very  much  in  distinctness  of  vision  by  squinting;  there- 
fore, they,  as  a  rule,  do  not  fall  into  the  habit.  Patients  with 
a  very  moderate  degree  of  hypermetropia  do  not  ordinarily 
need  to  sacrifice  binocular  vision  to  their  fairly  distinct  percep- 
tion of  small  objects.  It  is,  therefore,  chiefly  in  the  medium 
degrees  of  hypermetropia,  that  strabismus  convergens  is  ob- 
served. 

From  this  causation  of  convergent  strabismus  it  is  evident, 
that  there  must  be  some  time  in  the  period  of  its  development 
at  which  a  proper  correction  by  convex  glasses  and,  perhaps, 
added  to  it  the  continued  paralyzation  of  the  accommodation 
and  consequently  of  convergence,  may  bring  about  a  cure. 
Such  is,  indeed,  the  case,  when  the  patient  is  seen  early 
enough,  which,  however,  but  rarely  happens. 

§127.  Myopia  {short-sight  or  near-sightedness)  is,  as  stated 
above,  that  condition,  in  which  the  eye,  when  perfectly  at  rest, 


234  OPHTHALMOL  OGY. 

is  focussed  for  divergent  rays,  and  in  which  parallel  rays  en- 
tering through  the  cornea  are  united  into  a  point  before  they 
reach  the  retina.  This  causes  the  retina. to  receive  disper- 
sion circles  from  far  objects,  and  consequently  such  objects 
appear  indistinct.  On  the  other  hand,  near  objects  are 
seen  clearly  and  without  a;ccommodative  effort,  but  pro- 
longed convergence  is  often  made  irksome  by  weak  internal 
recti  muscles. 

Concave  glasses  enable  myopic  eyes  to  see  distant  objects 
distinct  by  rendering  the  parallel  rays  divergent  and  the  slight- 
ly divergent  rays  more  divergent,  before  they  touch  the  cornea. 


Fig.  97. — Ophthalmoscopic  appearance  of  the  optic  papilla  and  crescent  in  a  myopic 
.  eye.  , 

In  myopia  the  eyeball  is  too  long  in  comparison  with  an  em- 
metropic eye.  This  may  be  a  congenital  condition,  or  it  maybe 
acquired.  The  fact  that  among  uncivilized  nations  myopia  is  al- 
most unknown,  and  that  it  is  pre-eminently  an  affection  belong- 
ing to  civilized  life,  shows  us  that  its  chief  causes  are  to  be 
sought  in  early  and  prolonged  application  to  study,  and  especi- 
ally under  the  unfavorable  conditions  of  small  print,  badly  ar- 


ERR ORS  OF  REFRA C TION  AND  A CCOMMODA  TION.         235 

ranged  desks,  which  allow  of  or  even  actually  lead  the  child 
to  assume  a  stooping  posture,  badly  lighted,  badly  ventilated 
and  overheated  school  rooms,  badly  arranged  or  insufficient 
artificial  illumination,  etc.  Under  such  influences  the  child's 
eyes,  if  there  is  any  inherited  tendency  will  certainly  become 
myopic. 

§128.  The  elongation  of  the  eyeball  gives  rise  to  certain 
ophthalmoscopic  changes  in  the  background  of  a  myopic  eye. 
The  most  constant  symptom  (although  it  may  be  observed 
in  eyes  which  are  not  myopic)  is  the  appearance  of  a  crescent- 
shaped  white  figure,  by  which  the  disk  is  apparently  enlarged 
towards  the  macula  lutea.  (See  Fig.  97).  This  crescent  may 
vary  in  its  position  and  size,  and  the  white  figure  may  form  a 


Fig.  98. — Shows  how,  by  the  formation  of  a  posterior  scleral  staphyloma  in  progres- 
sive myopia,  the  vitreous  body  becomes  detached  from  the  retina.  The 
space  so  formed  is  filled  by  serum. 

closed  ring  around  the  papilla.  That  this  appearance  is  due 
to  a  change  in  the  choroid  is  evidenced  by  the  fact  that  the 
retinal  bloodvessels  pass  over  it  undisturbed.  When  there  is 
not  only  an  atrophic  crescent,  but  a  real  congenital  or  ac- 
quired bulging  of  the  posterior  segment  of  the  eyeball,  we 
speak  of  a  posterior  scleral  staphyloma.  By  the  gradual  in- 
crease of  such  a  staphyloma  the  vitreous  body  becomes  de- 
tached and  a  space  is  formed  between  it  and  the  retina,  which 
is  filled  by  serum.  (See  Fig.  98).  The  staphyloma  also  leads 
to  a  bend  in  the  optic  nerve  at  its  entrance  in  such  a  manner 
that  the  papilla  seems  to  be  dragged  towards  the  macula  lutea. 


236  OPHTHALMOLOGY. 

By  this  means  the  inter-vaginal  space  of  the  optic  nerve  near 
the  sclerotic  becomes  much  wider  than  normal,  and  it  pene- 
trates sometimes  far  into  the  sclerotic. 

§129.  Myopia  may  remain  comparatively  or  altogether  sta- 
tionary, or  it  may  be  progressive  and  become  malignant.  In 
the  latter  case,  aside  from  the  staphyloma  and  atrophy  due  to 
the  stretching  of  the  retina  and  choroid,  symptoms  of  an  in- 
flammatory nature  appear  in  the  posterior  part  of  the  eyeball, 
and  characterize  the  process  as  a  choroiditis.  With  every 
new  inflammatory  attack  new  territory  is  invaded,  and  not  in- 
frequently the  region  of  the  macula  lutea  is  thus  rendered 
blind.  Floating  opacities  in  the  form  of  muscae  volitantes,  or 
larger  fibrinous  flocks,  are  never  wanting  and  sub-retinal  haem- 
orrhages may  appear. 

The  pupil  is  usually  larger  in  myopic  than  in  emmetropic 
eyes.  To  obviate  the  indistinctness  of  vision,  due  to  the  dif- 
fused light  admitted  through  the  large  pupil,  myopic  patients 
get  into  the  habit  of  partially  covering  their  pupils  by  squeez- 
ing the  eyelids  together  or  by  actually  flattening  the  cornea 
by  this  pressure  of  the  lids. 

The  elongation  of  myopic  eyes  causes  them  to  appear  full 
and  prominent. 

§130.  Although  distant  vision  is  very  indistinct  in  myopia, 
the  sight  for  small  near  objects  is  excellent  (at  least  where  the 
inflammatory  changes  have  not  gone  too  far),  so  that  small 
objects  which  an  emmetropic  eye  can  see  only  by  the  aid  of 
a  weak  magnifying  glass,  may  sometimes  be  seen  with  ease  by 
a  myopic  eye.  The  amount  of  accommodative  power  used 
by  a  myopic  eye  is  very  small,  and  in  this,  probably,  lies  the 
reason  why  the  converging  (internal  recti)  muscles  are  also 
weak  and  often  insufficient  for  prolonged  binocular  vision.  The 
elongated  shape  of  the  myopic  eyeball  is  furthermore  a  mechan- 
ical hindrance  to  convergence.  This  insufficiency  of  the  inter- 
nal recti  muscles  gives  rise  also  to  asthenopic  symptoms  due 
to  fatigue  of  the  external  muscular  apparatus,  and  leading  to 
a  loss  of  balance  between  the  internal  and  the  external  recti, 
so  that  at  length  one  eye  refuses  the  strain  on  the  internal  rec- 


ERRORS  OF  REFRACTION  AND  ACCOMMODATION.  237 

C 

tus,  and  becomes  passively  everted  by  the  unopposed  action  of 
the  external  rectus.  To  do  away  with  the  disagreeable  double 
images  which  now  appear  and,  in  order  not  to  give  up  the 
feeling  of  comfort  caused  by  the  relaxation  of  his  converging 
muscles,  the  patient  gradually  allows  the  external  rectus  mus- 
cle more  and  more  liberty  of  action,  and  finally  a  condition  of 
permanent  divergent  strabismus  is  established. 

Myopes,  as  they  grow  old,  have  a  certain  advantage  over 
emmetropes  and  hypermetropes  in  their  partial  or  total  exemp- 
tion from  the  necessity  of  using  convex  glasses  for  reading,  but 
they  do  not,  as  is  often  erroneously  assumed,  become  normal- 
sighted  for  the  distance. 

The  concave  glasses  prescribed  in  myopia  ought  to  be  the 
weakest  with  which  the  normal  acuteness  of  vision  is  obtained. 
The  question  whether  a  patient  ought  to  wear  his  glasses  con- 
stantly or  only  for  distant  vision,  or  whether  he  should  use 
glasses  of  different  strength  for  distant  vision  and  for  near 
work,  depends  mainly  on  the  degree  of  his  myopia,  and  upon 
the  period  of  life  at  which  the  glasses  are  prescribed.  The 
sooner  accurately  correcting  glasses  are  worn,  the  better  it  is, 
as  a  rule,  for  the  patient,  and  in  as  much  as  the  corrected  eye 
must  use  its  accommodation  for  near  work,  it  is  usually  best  to 
encourage  children  to  wear  their  correcting  glasses  constantly. 
In  very  high  degrees  of  myopia  and  in  advanced  age  a  glass 
somewhat  weaker  than  that  which  perfectly  corrects  the  myo- 
pia, should  be  given. 

Whenever  a  case  of  myopia  shows  decided  signs  of  pro- 
gressiveness  or  malignancy,  prolonged  rest  from  all  use  of  the 
eyes  should  be  enforced.  To  this  may  be  advantageously 
added  the  instillation  of  atropia. 

Synchisis  of  the  vitreous  body  and  detachment  of  the  retina 
are  apt  to  occur  in  myopic  eyes,  as  has  been  already  stated 
above. 

§131.  Astigmatism,  asymmetry  of  curvature  in  the  cornea 
(or  crystalline  lens),  is  the  condition  in  which  the  different  me- 
ridians of  the  refractive  surfaces  have  unequal  radii  of  curva- 
ture. To  a  slight  degree  this  inequality  exists  even  in  the 
normal  eye.     When  it  is  somewhat  exaggerated,  however,  the 


238  OPHTHALMOL  OGY. 

sight  becomes  blurred,  and  details  of  objects  appear  more  or 
less  distorted  for  the  reason  that  the  unsymmetrical  refractive 
surface  can  have  no  perfect  focus  for  the  rays  which  pass 
through  it,  but  only  a  series  of  approximate  foci  lying  along  a 
line  which  has  been  given  the  name  of  focal  interval.  (See 
Fig.  99). 


Oo-»  0 


Fig.  99. — Refraction  of  parallel  rays  passing  through  the  asymmetridally  curved  cor- 
nea in  regular  astigmatism.  A.  The  refraction  by  the  meridian  of  highest 
curvative.  B.  The  refraction  by  the  meridian  of  least  curvature.  C.  Outline 
of  a  bundle  of  rays  refracted  by  an  asymmetrically  curved  cornea.  The  rays 
are  united  in  two  focal  lines  corresponding  to  the  foci  of  the  principal 
meridians.     The  space  between  them  is  called  the  focal  interval  of  Sturm. 

The  name  regular  astigmatism  is  given  to  those  cases  in 
which  the  refracting  surface  is  of  a  regular  ovoid  form,  instead 
of  being  a  segment  of  a  sphere.  In  this  form  of  astigmatism 
we  recognize  a  meridian  of  greatest  and  one  of  least  refraction, 
which  two  meridians  lie  usually  at  right  angles  to  each  other  and 
are  called  the  principal  meridians.     In  astigmatism,  according 


ERRORS  OF  REFRACTION  AND  ACCOMMODATION,  239 

to  the  rule,  the  vertical  meridian  (or  a  meridian  near  the  vertical 
one),  is  the  more  strongly  curved,  while  the  horizontal  one  (or 
a  meridian  near  it)  is  the  least  curved  one.  When  this  condition 
is  reversed,  as  we  find  in  a  number  of  cases,  we  speak  of  astig- 
matism against  the  rule.  The  astigmatic  eye  may  be  emmetro- 
pic in  either  of  its  principal  meridians,  in  which  case  it  will  be 
either  myopic  or  hypermetropic  in  the  other,  and  we  call  this 
condition  simple  myopic  or  hypermetropic  astigmatism.  If  the 
eye  is  myopic  in  both  meridians  it  is  called  compound  myopic 
or  if  hypermetropic  in  both  meridians,  compound  hypermetropic 
astigmatism^  and  if  it  is  myopic  in  one  and  hypermetropic  in  the 
other  principal  meridian,  the  condition  is  called  mixed  astig- 
matism. All  forms  of  regular  astigmatism  may  be  corrected 
by  means  of  a  piano-cylindrical  lens  of  the  proper  radius  of 
curvature,  so  placed  before  the  eye  as  to  equalize  its  refractive 
power  in  the  two  principal  meridians,  and,  if  any  ametropia 
remains,  this  may  be  corrected  by  grinding  the  proper  spheri- 
cal surface  upon  the  other  side  of  the  same  lens. 

As  a  varying  small  amount  of  astigmatism  exists  in  almost 
every  eye,  we  may  speak  of  normal  astigmatism.  It  is  due  to 
this  normal  astigmatism  that  most  of  us  do  not  see  the  stars 
as  round  bodies,  but  as  stars. 

While  some  patients  will  hardly  be  conscious  of  quite  a 
marked  degree  of  astigmatism  and  will  even  refuse  to  have  it 
corrected  by  glasses,  others  suffer  from  a  degree  of  astheno- 
pia which  seems  out  of  all  proportion  to  the  small  degree  of 
astigmatism  found  on  examination,  and  get  relief  only  from  its 
correction  by  glasses. 

Regular  astigmatism  is  nearly  always  congenital. 

When  the  curvature  of  the  refracting  surface  is  irregular,  we 
call  the  condition  irregular  astigmatism.  This  condition  is 
mostly  due  to  former  inflammatory  processes   in  the  cornea. 

Even  in  irregular  astigmatism  vision  may  sometimes  be  ma- 
terially benefitted  by  spherico- cylindrical  or  cylindrical  glasses. 

§132.  When  the  refractive  power  of  the  two  eyes  is  not 
alike,  the  condition  is  called  anisometropia.  What  glasses  are 
to  be  used  in  such  cases  must  depend  on  the  special  require- 
ments of  each  case.     It  may  be  well  to  give  a  correcting  glass 


240  OPHTHALMOLOGY. 

for  each  eye,  if  the  difference  is  small;  in  other  cases  it  is  bet- 
ter to  give  glasses  for  the  same  focus  for  both  eyes.  Even 
when  one  eye  is  hypermetropic  and  the  other  myopic,  a  condi- 
dition  which  might  seem  to  be  quite  comfortable,  some  pa- 
tients want  a  correction.  When  the  difference  in  the  degree 
of  refraction  is  too  great  to  give  to  each  eye  its  correcting 
glass,  the  glass  which  gives  most  comfort  should  be  given.  In 
correcting  astigmatism  each  eye  must  be  separately  considered. 

All  forms  of  ametropia  can  be  diagnosticated  by  the  use  of 
the  ophthalmoscope,  when  the  patient's  and  the  observer's  ac- 
commodation are  perfectly  relaxed,  and,  if  the  observer  be 
himself  not  emmetropic,  when  his  ametropia  is  corrected. 

Other  methods  may  be  used  to  make  the  result  of  the  ex- 
amination more  certain,  and  different  apparatus  have  been  de- 
vised by  means  of  which  we  are  enabled  to  make  a  perfectly 
objective  examination  for  astigmatism.  It  does,  however,  not 
lie  within  the  scope  of  this  book  to  do  more  than  to  refer  to 
their  existence.  The  two  principal  auxilliary  methods  are 
skiascopy  {koroscopy,  shadow-test)  and  keratoscopy.  In  the 
former  the  direction  and  manner  of  the  excursions  which  the 
shadow  of  the  iris  will  make  across  the  lighted  pupil  when  the 
ophthalmoscope,  through  which  it  is  viewed,  is  turned  from 
side  to  side,  are  made  use  of  for  measuring  the  refraction.  In 
the  second,  the  direction  and  degree  of  the  distortion  or  dis- 
placement of  an  image  reflected  on  the  cornea  are  the  means 
of  gaining  a  knowledge  of  the  existence  and  degree  of  astig- 
matism. The  best  instrument  for  the  purpose  of  examining 
for  astigmatism  is  the  ophthalmometer  oi  Javal  &  Schiotz. 

It  cannot  be  expected  that  every  physician  shall  be  able  to 
make  an  exhaustive  examination  of  the  refractive  condition  of 
a  patient's  eye.  Nevertheless  he  should  be  familiar  with  the 
symptoms  of  ametropia,  and  especially  of  asthenopia,  so  that 
he  may  advise  the  selection  of  glasses  when  needed,  and, 
moreover,  see  to  it,  that  when  prescribed,  the  glasses  are  worn 
as  directed  by  the  oculist.  It  is  not  only  young  ladies  and 
gentlemen  who  from  vanity  often  refuse  to  wear  glasses,  even 
though  conscious  that  they  are  greatly  benefitted  by  them. 
Frequently  the  imperfectly  educated  parents  will  not  allow 
their  children  to  wear  glasses  at  an  age   when,  perhaps,   the 


ERRORS  OF  REFRACTION  AND  ACCOMMODATION.         241 

child's  whole  future  may  depend  upon  their  use.  The 
common  prejudice  against  the  wearing  of  glasses,  and 
especially  of  convex  glasses,  by  young  persons,  is  not  only 
unfounded,  but  it  often  leads  to  infinite  harm.  No  one  would 
refuse  a  patient  with  crippled  legs  the  assistance  of  crutches, 
yet,  to  refuse  the  crippled  eye  the  use  of  glasses  is  often  a 
much  greater  wrong. 

Furthermore,  as  asthenopsia  of  some  kind  may  cause  all 
sorts  of  otherwise  unexplained  nervous  symptoms,  among 
which  headache  plays  the  chief  role,  such  symptoms  should 
lead  the  physician  to  advise  a  thorough  examination  of  the 
eyes  before  other  methods  of  treatment  are  instituted.  The 
cases  in  which  such  symptoms,  due  to  asthenopia,  are  allowed 
to  make  a  life  miserable  and  to  render  the  patient  unfit  for  any 
application  to  near  work,  are  still  too  commonly  sent  from  one 
physician  to  another  without  relief,  when  a  thorough  examina- 
tion of  the  eyes  might  readily  lead  to  the  recognition  of  the 
cause  and  its  cure. 

§133.  When  speaking  of  the  function  of  accommodation,  it 
was  mentioned  that  with  advancing  years  this  faculty  is  gradu- 
ally lost,  and  that  this  causes  the  near-point  to  recede  more 
and  more  from  the  eye.  Thus  we  find  that  while  at  10  years  of 
age  the  near  point  lies  at  about  three  inches  from  the  eye,  at 
20  years  it  is  about  4,  at  30  years  about  6,  at  40  years  about  9, 
at  45  years  about  12,  and  at  50  years  about  16  inches  from  the 
eye.  From  the  fact  that  the  range  of  binocular  accommoda- 
tion is  somewhat  less  than  that  of  monocular  accommodation, 
the  near-point  for  perfect  binocular  vision  is  even  further  from 
the  eyes  than  these  figures  would  indicate.  The  cause  of  this 
progressive  loss  of  accommodative  power  lies  in  the  physio- 
logical hardening  of  the  crystalline  lens,  which  renders  it  less 
and  less  capable  of  changing  its  form  to  meet  the  require- 
ments of  near  vision  {presbyopia,  old  sight). 

As  soon  as  the  binocular  near-point  has  receded  beyond  12 
inches  from  the  eyes,  reading,  especially  at  night.and  for  fine 
print,  becomes  uncomfortable.  More  light  is  required  to  see 
distinctly,  and  as  the  book  must  be  held  so  far  away  as  to  allow 
the  lamp  to    be  easily  placed  between  the  book  and  the  eyes. 


242  OPHTHALMOLOG  V. 

this  remedy  is  usually  at  first  resorted  to.  The  comfort  thus 
received  is,  moreover,  due  in  part  to  the  contraction  of  the 
pupil  in  bright  light,  and  the  consequent  exclusion  of  dispers- 
ion circles. 

§134.  Paralysis  of  the  accommodation  causes  the  same 
symptoms  as  presbyopia.  However,  the  pupil  is  in  most  cases 
at  the  same  time  perfectly  dilated,  while  in  other  cases  it  may 
remain  unchanged.  Presbyopia  always  affects  both  eyes,  pa- 
ralysis of  the  accommodation  may  happen  either  in  one  or  in 
both. 

If  paralysis  of  the  accommodation  affects  a  myopic  eye,  it 
will,  like  presbyopia,  cause  less  inconvenience  than  when  it 
occurs  in  an  emmetropic  eye.  If  it  occurs  in  a  hypermetropic 
eye,  distant  vision  also  becomes  indistinct.  Moreover,  when  in 
a  case  of  paralysis  of  the  accommodation,  as  is  often  the  case, 
the  sphincter  pupillae  is  also  paralyzed,  the  diffuse  light  ad- 
mitted into  the  eye  through  the  dilated  pupil,  causes  still 
greater  confusion  of  sight  than  in  a  case  in  which  the  pupil  is 
not  increased  in  size. 

Paralysis  of  the  accommodation  is  a  sign  of  some  affection 
of  the  oculomotor  nerve.  It  may  be  either  an  affection  of  the 
peripheral  branches  only,  or  the  symptom  of  some  central  le- 
sion. The  most  frequent  cause  of  monocular  paralysis  of  the 
accommodation  is  syphilis.  Other  causes  of  such  a  paralysis 
are  diphtheria,  tumors  of  the  brain,  poisoning  with  foul  meat, 
fish,  blood-sausage,  and  with  certain  drugs  like  belladonna, 
gelsemium,  etc.  Paralysis  of  the  accommodation  may  also 
follow  an  injury  to  the  eyeball. 

The  loss  of  accommodative  power  which  occurs  in  connection 
with  diphtheria,  is  generally  incomplete,  and  is  rather  a  paresis, 
than  an  actual  paralysis.  This  paresis  usually  comes  on  sev- 
eral weeks  after  the  diphtheritic  process  in  the  throat  has  run 
its  course;  it  may  be  the  only  paresis  following  this  disease, 
and  it  may  appear  conjoined  with  paresis  of  the  muscles  of  the 
palate,  etc.  The  inability  to  read  in  this  affection  is  sometimes 
mistaken  for  obstinacy,  and  thus  the  child  is  liable  to  be  mis- 
understood, and  perhaps  punished  for  his  supposed  fault;  the 
physician  should,  therefore,  always  bear  in  mind  that  paralysis 


ERR ORS  OF  REFRA C TION  AND  ACC OMMODA TION.  243 

of  the  accommodation  is  a  not  infrequent  sequel  of  diphtheria 
of  the  throat,  and  should  warn  the  parents  that  the  child's  vis- 
ion may  possibly  become  affected,  especially  when  other  paral- 
yses have  developed. 

In  all  such  cases  the  child  ought  to  be  kept  from  school  un- 
til perfectly  well,  although  the  use  of  a  convex  glass  will  en- 
able him  to  read  easily.  Tonic  treatment  and  rest  will  help  to 
get  him  over  the  paresis,  and,  even  if  nothing  is  done  in  the 
way  of  medication,  a  few  weeks'  time  will  generally  restore 
the  accommodation.  The  instillation  of  mild  miotic  agents 
seems  to  shorten  the  time  necessary  for  the  recovery. 

Spasm  of  the  accommodative  apparatus,  leading  to  apparent 
myopia,  is  sometimes  observed  in  hypermetropic  eyes,  and  is 
usually  very  troublesome.  If  it  happens  in  a  myopic  eye  the 
degree  of  myopia  is  apparently  increased.  The  treatment 
must  be  directed  to  the  full  relaxation  of  the  accommodative 
apparatus,  together  with  the  correction  of  any  existing  ame- 
tropia. 


CHAPTER    XXL— DISEASES     OF    THE    EXTERNAL 
MUSCLES    OF    THE    EYE. 

§135.  The  eyeball  can  be  moved  upon  its  centre,  in  an  infinite 
variety  of  directions.  This  is  accomplished  by  means  of  the 
external  muscles,  the  rectus  superior  a7id  inferior,  the  rectus  in- 
ternus  and  externus  and  the  obliquus  superior  and  inferior.  The 
four  recti  muscles,  as  stated  in  Chapter  I  (see  Fig.  100),  spring 


Fig.  I(X). — (After  Merkel).  Shows  the  manner  in  which  the  external  ocular  muscles 
(except  the  obliquus  inferior)  take  their  origin  from  the  bones  around  the 
optic  foramen.  R  S.  Rectus  superior.  R  E.  Rectus  exterior.  R  I  f. 
rectus  inferior.  R  I.  Rectus  internus.  O  S.  Obliquus  superior.  P  S. 
levator  palpebrae  superioris. 

from  the  apex  of  the  orbit,  around  the  optic  foramen,  and  are 
inserted  upon  the  sclerotic  at  different  distances  from  the  cor- 
neo-scleral  margin.  The  superior  oblique  muscle  also  takes 
its  origin  at  the  apex  of  the  orbit,  and  is  inserted  in  the  scle- 
rotic, but  only  after  its  tendon  has  passed  around  the  trochlea. 
The  inferior  oblique  muscle  springs  from  the  inner  surface  of 
the  orbit  near  its  inferior  and  nasal  margin,  and  then  goes  to 
the  eyeball. 

The  action  of  the  two  oblique  muscles  is,  of  course,  differ- 
ent from  that  of  the  recti,  since  their  direction  (See  Fig.  10 1) 
from  their  punctum  fixum  (trochlea  at  the  inner  upper,  and 
origin  of  the  lower  oblique  at  the  inner  lower  orbital  margin) 

—244— 


DISEASES  OF  THE  EXTERNAL  MUSCLES.  245 

is  backwards  and  outwards.     The  distances  from  the  corneo- 


FiG.  loi. — Manner  in  which  the  external  ocular  muscles  are  inserted  on  the  sclerotic 
(right  eye).  The  obliquus  superior  passes  through  a  loop  and  thus  its  course 
is  changed.    The  obliquus  inferior  springs  from  the  lachrymal  bone. 

scleral   margin,  at  which  the  several  muscles  are  inserted  in 
the  sclerotic  are,  according  to  Merkelj  the  following  ones: 


Rectus  superior,     - 

- 

8.2] 

millimeters. 

Rectus  inferior, 

- 

7.2 

Rectus  internus,     - 

- 

6.5 

Rectus  externus,    - 

- 

6.8 

Obliquus  superior,  - 

- 

16.0 

Obliquus  inferior,  - 

- 

18.3 

These,  of  course,  are  average  numbers.     (See  Fig.  102). 

These  muscles  may  act  either  singly  or  in  various  combina- 
tions. When  acting  singly  the  internal  rectus  turns  the  eye- 
ball strictly  horizontally  inward,  the  external  rectus  in  the 
same  way  turns  it  outward;  the  superior  rectus  which  is  insert- 
ed somewhat  to  the  nasal  side  of  the  median  plane  of  the  eye- 
ball, turns  the  eyeball  upwards  and  slightly  inwards,  and  ro- 
tates the  upper  end  of  its  vertical  meridian  towards  the  nose; 
the  superior  oblique  turns  the  eyeball  downwards  and  out- 
wards, and  rotates  the  upper  end  of  the  vertical  meridian  of 
the  cornea  also  towards  the  nose;  the  inferior  rectus  turns  the 
eyeball  downwards,  and  a  little  inwards,  and  rotates  the  upper 
end  of  its  vertical  meridian  towards  the  temple;  the  inferior 
oblique  turns  the  eyeball  upwards   and  outwards,  and  rotates 


246 


OPHTHALMOL  OGY. 


the  upper  end  of  the  vertical  meridian  of  the  cornea  also  to- 
wards the  temple. 

When  the  superior  rectus  and  inferior  oblique  act  together, 
the  eye  is  turned  vertically  upwards,  and  by  the  combined  ac- 
tion of  the  inferior  rectus  and  the  superior  oblique  the  eyeball 
is  turned  vertically  downwards. 


Fi(i.  I02. — (After  Merkel).  Location  of  the  insertions  of  the  external  ocular  muscles, 
a — i.  Rectus  inferior;  s.  Rectus  superior.  The  other  two  lines  refer  to  the 
rectus  externus  and  Obliquus  inferior,  b — 1.  Rectus  externus;  m.  Rectus  in  - 
ternus.  The  third  line  refers  to  the  rectus  inferior,  c — i  and  s,  as  above. 
The  third  line  refers  to  the  Rectus  Internus.  d — 1  and  m,  as  above.  The 
other  two  lines  refer  to  the  Rectus  superior  and  Obliquus  superior  and 
show  the  angle  at  which  the  latter  reaches  the  eyeball. 

If  the  eyeball  is  turned  upwards  and  outwards,  the  superior 
rectus,  the  external  rectus  and  the  inferior  oblique  come  into 
play;  if  downwards  and  outwards,  the  inferior  rectus,  external 
rectus  and  the  superior  oblique  are  in  play,  etc.  Thus  in  all 
movements,  except  those  in  the  horizontal  plane,  at  least  two 
and  generally  three  muscles  must  act  conjointly. 

§136.  When  all  the  muscles  of  both  eyes  act  in  proper  har- 
mony, perfect  binocular  vision  is  the  result,  and  two  retinal 
images  are  perceived  by  the  brain  as  one  object;  but,  if  any 
one  muscle  refuses  to  perform  its  part,  or  is  paralyzed,  the 
two  images  will   no  longer  fall  on  corresponding  parts    of  the 


DISEASES  OF  THE  EXTERNAL  MUSCLES. 


247 


two  retinae  and  double  vision  (diplopia)  must  follow.    (See  Fig. 
103).  The  double  or  false  image  may  be  homonymous.    It  then 


Fig.  103. — Homonymous  diplopia  in  convergent  strabismus. 

appears  on  the  side  of  the  object  looked  at,  corresponding  to 
the  eye  in  which  the  double  image  is  perceived,  or  it  may  be 
heteronymous  (crossed  image),  in  which  case  it  appears  to  be  on 
the  opposite  side    of  the    object.     When  one    of  the  eyes   is 


Fig.  104. — Heteronymous  diplopia  in  divergent  strabismus. 

turned  abnormally  inwards  towards  the  nose,  the  false  image 
is  homonymous;  when  one  eye  is  turned  abnormally  outwards 
towards  the  temple,  the  false  image  is  heteronymous.  (See 
Fig.  104). 


248  OPHTHALMOLOGY 

The  oculomotor  nerve  directs  the  movements  of  all  of  the 
muscles  of  the  eyeball  except  those  of  the  superior  oblique 
and  the  external  rectus.  These  two  muscles  have  each  its  own 
special  nerve,  namely:  the  trochlearis  nerve  for  the  superior 
oblique  and  the  abducens  nerve  for  the  external  rectus.  The 
movements  which  the  eyeball  makes,  when  certain  of  its  muscles 
act,  being  known  to  us,  it  is  clear  that  the  position  of  the  false 
image  will  not  only  tell  us  what  muscle  or  groupe  of  muscles 
refuse  to  act,  but  also  which  of  the  cerebral  nerves  may  be 
affected.  The  diplopia  is,  therefore,  often  a  symptom  of  great 
value  in  diagnosticating  brain  lesions,  and  may  even  help  in 
locating  them. 

According  to  the  degree  of  insufficiency  of  the  muscle  af- 
fected the  false  image  will,  in  the  positions  of  the  eye  which 
evoke  it,  appear  nearer  to  or  farther  from  the  real  image.  The 
disagreeable  consequences  of  seeing  double  are  greatest  when 
the  distance  between  the  two  images  is  small;  when  this  dis- 
tance is  very  large,  the  false  image  is  disregarded,  or  it  may 
even  not  be  seen  at  the  same  time  with  the  real  one. 

In  order  to  overcome  diplopia,  the  patient  will  supplement 
the  diminished  action  of  the  weakened  muscle  of  the  eyeball 
by  turning  his  head  in  its  direction.  For  instance,  if  the  right 
eyeball  cannot  be  abducted  in  consequence  of  paralysis  of  the 
external  rectus,  every  object  lying  in  this  direction  will  appear 
double,  as  long  as  the  patient  gazes  in  this  direction,  but  a 
turn  of  the  head  in  the  same  direction  will  enable  him  to  see 
single.  From  this  position  of  the  head,  which  after  a  while 
becomes  habitual,  we  can  often  conclude  in  which  muscle,  or 
groupe  of  muscles,  the  affection  lies. 

§137.  Diplopia  maybe  brought  about  by  any  obstacle  in  the 
way  of  proper  action  of  one  or  more  muscles  of  the  eyeball,  as 
orbital  tumors,  orbital  cellulitis  or  other  causes,  but  it  is  most  fre- 
quently produced  hy  paralysis  of  one  or  more  muscles,  and  this 
again  is  mostly  due  either  to  cerebral  syphilis  or  to  some  other 
brain  lesion.  It  has  also  been  observed  as  the  result  of  ma- 
larial poisoning.  Paralysis  of  all  external  muscles  of  the  eye, 
ophthalmoplegia  externa,  is  seen  in  rare  cases. 

In  cases  of  paralysis  of  one  muscle  of  the  eye  we  find  after 


DISEASES  OF  THE  EXTERNAL  MUSCLES.  249 

some  time  a  secondary  contraction  of  the  antagonistic  muscle 
just  as  we  do  in  paralysis  of  other  muscles  of  the  body.  The 
affection  may  thus  bring  about  a  form  of  strabismus  which  we 
call  paralytic  strabismus,  to  distinguish  it  from  the  typical  or 
muscular  strabismus.  In  paralytic  strabismus  the  secondary 
deviation  of  the  healthy  eyeball,  when  covered,  is  greater  than 
the  deviation  of  the  affected  eye,  while  in  typical  muscular 
strabismus  the  primary  and  the  secondary  deviation  are  equal. 
(See  Chapter  II). 

Paralysis  of  the  external  rectus  is  the  most  frequent  cause  of 
diplopia.  If  partial,  the  muscle  may  be  able  to  move  the  eye- 
ball somewhat  beyond  the  medium  line  of  the  orbit,  if  total, 
it  cannot  move  the  eyeball  at  all,  and  convergent  paralytic 
squint  will  soon  follow.  Diplopia  must,  of  course,  exist  in  all 
movements  of  the  eyeball  in  which  the  external  rectus  ought 
to  act.  (The  method  of  examining  for  double  images  has 
been  detailed  in  Chapter  II).  The  diplopia,  characteristic  of 
paralysis  of  the  external  rectus,  appears,  therefore,  in  the  outer 
half  of  the  binocular  visual  field.     (See  Fig.  105).      The  false 


I 


,/Z^^>^Cc<r   -^^^^^e^t"*^ 


t<^ 


Fig.  105. — Position  of  the  two  images  in  paralysis  of  the  rectus  externus.     The  real 
image  is  black,  the  double  image  striated.     R,  right  eye.    L,  left  eye. 

image  stands  on  the  temporal  side  of  the  real  one.  The  dis- 
tance between  the  two  images  increases,  the  farther  the  eyes 
are  turned  towards  the  side  of  the  paralyzed  muscle.  In  pro- 
portion, however,  as  the  secondary  contraction  of  the  internal 
rectus  becomes  established,  the  diplopia  extends  over  the 
whole  field  of  vision. 

Paralysis  of  the  superior  oblique  causes  the  double  images  to 
appear  when  the  patient  looks  below  the  horizontal  line.  The 
two  images  do  not  stand  at  an  equal  height,  but  the  one  be- 
longing to  the  affected  eyeball  stands  lower  than  the  other  and 


250  OPHTHALMOL  OGY, 

converges  towards  it  with  its  upper  end.  (See  Fig.  io6).  The 
vertical  distance  between  the  images  increases  when  the  eyes 
are  converged  and  look  downwards,  and  the  slanting  direction 
of  the  false  image  increases  when  the  eye  is  abducted. 


Fig.  io6. — Position  of  tlie  two  images  in  paralysis  of  the  obliquus  superior. 

If  the  internal  rectus  only  is  paralyzed,  the  double  image 
appears  when  the  eyes  are  turned  towards  the  healthy  side, 
and  is  on  the  nasal  side  of  the  true  image.  (See  Fig.  107). 
The  more  the  eyes  are  turned  towards  the  healthy  side,  the 
farther  the  images  are  removed  from  each  other. 


I 


oC      B  >^Z^^^^^Sv><-<^^€.^S't.<.^k<. 


Fig.  107. — Position  of  the  two  images  in  paralysis  of  the  rectus  externus. 

Paralysis  of  the  inferior  rectus  causes  double  vision  below 
the  horizontal  line.  The  false  image  stands  lower  than  the 
real  one  on  its  nasal  side,  and   slants  towards  it  with  its  upper 


yte.^>^^lc^  .yOc<^£UA< 


^7Xy 


Fig.  108. — Position  of  the  two  images  in  paralysis  of  the  rectus  inferior. 

end.  (Sec  Fig.  108).  The  images  become  farther  removed 
from  each  other  in  the  vertical  line,  if  the  eyes  are  turned 
downwards  and  abducted;  the  false  image  slants  more  during 
adduction. 


DISEASES  OF  THE  EXTERNAL  MUSCLES.  251 

In  paralysis  of  the  superior  rectus  the  diplopia  is  found 
above  the  horizontal  line.  (See  Fig.  109).  The  false  image 
stands  above  the  real  one  on  its  nasal  side,  and  slants  to- 
wards it  with  its  lower  end.  The  vertical  distance  between 
the  images  increases  when  the  eyes  are  turned  upward  and  ab- 
ducted; the  false  image  appears  more  slanting  when  the  eyes 
are  converged. 


--i^^^i^/c^C^^Un^. 


Fig.  109. — Position  of  the  two  images  in  paralysis  of  the  rectus  superior. 

When  the  inferior  oblique  is  paralyzed  there  is  diplopia  above 
the  horizontal  line.  (See  Fig.  no).  The  false  image  stands 
higher  than  the  real  one  on  its  temporal  side,  and  slants  to- 
wards it  with  its  lower  end.  The  vertical  distance  between  the 
two  images  is  increased  when  looking  up  and  converging.  The 
false  image  slants  more  during  abduction  of  the  affected  eye. 

Fig.  1 10. — Position  of  the  two  images  in  paralysis  of  the  obliquus  inferior. 

Paralysis  of  the  sphincter  pupillce  causes  mydriasis  (dilata- 
tion of  the  pupil)  and  is  mostly  combined  with  paralysis  of  the 
accommodative  apparatus.     (See  Chapter  XX). 

§138.  Paralysis  of  the  oculomotor  nerve  may  affect  only 
one  of  its  branches  in  the  manner  just  detailed,  but,  particular- 
ly when  it  is  of  central  origin,  it  affects  several  or  all  of  its 
branches  (levator  palpebrae  superioris,  rectus  superior,  internus 
and  inferior,obliquus  inferior,  sphincter  pupillae  and  ciliary  mus- 


252  OPHTHALMOLOGY. 

cle).  When  the  sphincter  pupillae  and  ciliary  muscle  are  af- 
fected alone  we  speak  of  ophthalmoplegia  interna.  In  some 
cases,  when  the  central  lesion  is  progressive,  a  paralysis  which 
originally  affected  but  one  branch  of  the  oculomotor  nerve 
may  gradually  affect  the  other  branches  one  after  another. 

When  the  paralysis  affects  but  one  muscle  it  is  usually  either 
the  external  rectus  or  the  superior  oblique  (trochlearis)  since 
they  have  separate  nerves.  The  prognosis  is  always  a  doubt- 
ful one. 

§139.  The  treatment  of  paresis  or  paralysis  of  the  muscles 
of  the  eye  must  take  into  consideration  their  probable  cause. 
If  syphilis  is  the  general  disease  which  has  produced  the  paral- 
ysis, internal  treatment  by  the  proper  drugs  may  be  followed 
by  success.  To  such  internal  treatment  may  be  added  the  lo-  >v 
cal  application  of  the  constant  galvanic  current.  In  si'me  cases^  ^ 
passive  movements  made  with  the  eyeball  in  the  direction  of  j 
the  paralyzed  muscle,  by  means  of  a  toothed  forceps,  yield 
good  and  prompt  results;  in  other  cases  they  prove  of  no 
value.  When  all  chances  of  an  improvement  in  the  action  of 
a  paralyzed  muscle  have  disappeared,  a  tenotomy  of  the  op- 
ponent, or  this  combined  with  the  advancement  of  the  affected 
muscle  may  sometimes  render  the  patient  more  comfortable. 
In  other  cases  prismatic  glasses  may  be  used  with  comfort, 
when  the  affection  has  become  stationary.  (Sometimes  they 
even  help  in  the  successful  treatment  of  a  paralysis).  When- 
ever the  patient's  life  is  in  jeopardy  from  the  double  vision,  as 
in  going  down  stairs  or  in  walking  on  and  crossing  frequented 
streets  and  so  on,  or  when  he  cannot  get  comfort  in  any  other 
way,  it  is  best  to  keep  the  affected  eye  covered. 

§140.  Typical  or  muscular  strabismus  almost  always  appears 
in  early  childhood,  and  is  characterized  by  excessive  muscular 
contraction.  This  prevents  the  patient  from  receiving  the 
image  of  the  object  looked  at  upon  the  yellow  spot  in  the  two 
eyes.  But,  while  in  paralytic  squint  the  eyeball  cannot  be 
moved  at  all  in  a  certain  direction,  although  there  is  binocular 
vision  in  other  directions,  the  eyeballs  move  nearly  equally 
well  in  all  directions  in  the  typical  muscular  squint,  only  they 


DISEASES  OF  THE  EXTERNAL  MUSCLES.  253 

cannot  both  fix  the  same  object  at  the  same  time,  and  there  is, 
therefore,  no  true  binocular  vision.  Double  images,  must,  of 
course,  exist  in  the  beginning  of  muscular  squint,  but  they  are 
usually  soon  either  disregarded  and  not  noticed  by  the  patient. 

Muscular  strabismus  is  practically  either  convergent  or  di- 
vergent, although  upward  and  downward  squint  are  seen  in  rare 
cases. 

The  causes  to  which  the  occurrence  of  the  squint  is  usually 
ascribed  by  the  parents  are  almost  infinite  in  their  variety,  and 
it  is  not  always  judicious  to  try  to  correct  their  error.  Bonders 
first  drew  attention  to  the  fact  that  an  error  of  refraction  ex- 
ists in  a  very  large  proportion  of  the  cases  of  strabismus. 
However,  the  number  of  cases  of  strabismus  in  which  no  ap- 
preciable error  is  found  is  not  very  small.  A  lack  of  equilib- 
rium between  the  antagonistic  muscles  is,  therefore,  in  these 
cases  the  only  explanation.  In  another  number  of  cases  opac- 
ities of  the  cornea,  or  in  the  crystalline  lens,  or  atrophic  spots 
in  the  choroid  and  retina  are  the  chief  cause  of  the  strabis- 
mus. In  some  cases  an  abnormal  shape  of  the  orbit,  or  an 
abnormal  distance  between  the  eyes  may  give  rise  to  squint. 

§141.  Generally  speaking  convergent  squint  is  most  frequent- 
ly found  in  combination  with  hypermetropia  and  hyperme- 
tropic astigmatism.  From  this  fact  it  is  clear,  as  pointed  out 
above,  that  in  such  a  case  the  timely  use  of  correcting  glasses 
may  prevent  the  development  of  the  strabismus.  In  practice, 
however,  this  is  generally  not  the  case,  except  when  the  ame- 
tropia is  corrected,  either  before  the  strabismus  has  shown 
itself  or  at  its  very  incipiency.  Later  on,  when  the  strabismus 
has  become  established,  the  glasses  will  no  longer  cure  it,  or 
perhaps  only  after  having  been  worn  for  a  very  long  period. 
All  other  contrivances,  such  as  opaque  spectacles  with  a  small 
central  hole,  or  spectacles  with  one-half  of  each  glass  ground 
dim,  etc.,  are   of  little  or  no  value   for  the  cure   of  strabismus. 

In  a  great  many  cases  of  strabismus  we  find  that  one  eye 
(the  deviating  one)  is  amblyopic,  and  the  question  is,  whether 
this  amblyopia  is  congenital,  and  has  existed  before  the 
squint,  or  whether  the  fact  that  this  eye  is  not  used  (at  least 
consciously)  brings  about  an  amblyopia  ''ex  anopsia.''     While 


254  OPHTHALMOLOGY. 

the  former  is  surely  often  the  case,  I  do  not  think  the  latter 
should  be  considered  improbable  {Schweigger,  Noyes),  as  we 
know  of  many  analogies  to  it  in  other  parts  of  the  human 
body.  Moreover,  not  infrequently  a  crossed  eye  is  observed 
to  become  decidedly  less  amblyopic  after  an  operation  for  stra- 
bismus. 

In  the  beginning  strabismus  is  usually  only  periodical,  and 
may  occasionally  remain  so  for  months,  or  even  years;  sooner 
or  later,  however,  it  almost  always  becomes  permanent. 

Convergent  strabismus  oftenest  makes  its  appearance  within 
two  or  three  years  after  birth,  when  the  child  begins  to  employ 
the  eyes  in  looking  intently  at  small,  near  objects,  toys,  pic- 
tures, letters,  etc.  It  is  said  to  be  sometimes  congenital,  but 
this  is,  to  say  the  least,  very  rare.  When  in  convergent  stra- 
bismus the  squinting  eye  moves  with  the  unaffected  one  and  to 
an  almost  equal  extent,  we  speak  of  strabismus  convergens  con- 
comitans. 

§142.  Divergent  squint  is  usually  associated  with  and  de- 
pendant on  myopia  and  myopic  astigmatism. 

Before  the  divergent  strabismus  becomes  pronounced,  insuf- 
ficiency of  the  internal  recti  is  always  observed.  In  this  con- 
dition the  convergence  of  the  eyes  in  near  vision  is  imperfect- 
ly maintained,  so  that  the  visual  axes  become  relatively  di- 
vergent, although  in  distant  vision  they  may  be  apparently  or 
actually  parallel.  Divergent  squint,  develops,  as  a  rule,  only 
slowly.  It  is,  moreover,  apt  to  come  on  at  a  more  advanced 
age  than  that  at  which  convergent  strabismus  usually  appears. 

Insufficiency  of  the  internal  recti  may  also  exist  without 
ever  developing  into  divergent  strabismus,  and  in  these  cases 
the  patients  can,  although  with  an  undue  effort,  converge 
enough  for  binocular  vision.  This  causes  athenopic  symptoms 
(muscular  asthenopia)  to  appear,  which  are  often  as  distressing 
as  the  asthenopia  which  depends  upon  the  undue  exertion  of 
the  accommodative  apparatus  in  hypermetropia. 

Such  insufficiency  of  action  may  be  observed  in  all  muscles 
of  the  eye,  and  asthenopic  symptoms,  may,  therefore,  be  due 
to  the  insufficiency  of  other  muscles  than  the  internal  recti. 

Such  a  muscular  asthenopia,  as  well   as  the  accommodative 


DISEASES  OF  THE  EXTERNAL  MUSCLES.  255 

asthenopia  (Chapter  XX),  may  give  rise  to  reflex  nervous  phe- 
nomena, especially  severe  headache  when  near  work  is  at- 
tempted. That  this  is  the  case  cannot  well  be  doubted,  but  in 
recent  years  this  influence  has  most  certainly  been  over-rated 
by  some  authors,  so  that  but  few  functional  nervous  diseases 
are  in  existence  of  which  muscular  asthenopia  has  not  by  some- 
one been  declared  to  be  the  cause. 

§143.  Permanent  strabismus  can  be  remedied  by  operation 
only.  This  operation  is  tenotomy  or  division  of  the  tendon  of 
the  contracted  muscle  of  the  squinting  eye,  and  when  neces- 
sary also  of  the  same  muscle  of  the  other  eye.  In  other  cases 
it  may  be  best  to  combine  tenotomy  on  one  eye  with  advance- 
ment of  the  tendon  of  the  antagonist,  or  the  advancement  of 
the  antagonist  of  the  contracted  muscle  alone  may  suffice.  A 
more  modern  procedure  is  the  advancement  of  Tenon's  capsule 
{von  Wecker)  over  the  antagonist. 

Whenever  the  strabismus  is  permanent  and  can  no  longer 
be  beneficially  influenced  by  glasses,  it  is  time  to  perform  these 
operations  in  order  to  obviate  the  amblyopia  ex  anopsia.  The 
age  for  operation,  therefore,  depends  on  the  lack  of  probabil- 
ity of  a  change  by  other  means.  When  it  has  to  be  done  in 
early  childhood,  it  is  well  to  confine  the  tenotomy  to  one  eye 
and  to  carefully  avoid  undue  cutting  of  tissues.  Cases  in 
which  a  well  developed  strabismus  will  disappear  without  sur- 
gical interference  are  extremely  rare,  although  they  occur 
occasionally. 

Insufficiency  of  any  of  the  external  muscles  of  the  eye  may 
be  improved  by  orthoptic  treatment  by  means  of  prisms.  If 
no  improvement  can  be  gained  in  this  manner  the  asthenopic 
symptoms  may  be  relieved  by  the  constant  wearing  of  pris- 
matic glasses  (or  the  decentration  of  spherical  lenses  when 
such  are  worn).  In  some  extreme  cases  no  relief  can  be  ob- 
tained by  these  means  and  an  operation  has  to  be  performed. 
This  is  best  done  by  total  tenotomy  of  the  comparatively  too 
strong  muscle.  Partial  tenotomies  have  been  introduced  of 
late  by  Stevens  and  have  found  their  admirers. 

§144.    Nystagmus  is   a   continuous    motion    of  the  eyeballs 


256  OPHTHALMOL  OGY. 

mostly  in  a  horizontal  but  sometimes  in  a  rotary  direction 
(pendulum  motion).  It  is  generally  observed  when  central 
vision  is  poor,  as  in  cases  of  congenital  amblyopia,  retinitis 
pigmentosa,  cataract,  scars  on  the  cornea,  albinism,  etc., 
or  it  may  develop  in  advanced  life  as  a  result  from  brain 
disease.  It  is  also  observed  to  attack  miners,  and  is  then  due  to 
the  cramped  position  in  which  these  men  have  to  work  and 
not  to  the  mode  of  illumination  and  poisonous  gases  as  has 
been  thought  {Snell), 

Treatment  is  useless,  except  in  miner's  nystagmus,  in  which 
form  rest,  fresh  air  and,  perhaps,  tonic  treatment  usually  affect 
a  cure. 


CHAPTER    XXII.— ON     THE     DIAGNOSTIC    VALUE 

OF    EYE-DISEASES     IN    INTRA-CRANIAL 

AFFECTIONS. 

§145.  It  is  not  very  long  since  it  was  thought  that  by  the  use 
of  the  ophthalmoscope  an  observer  could  look,  so  to  speak,  into 
the  brain,  or,  in  other  words,  that  from  the  conditions  of  the  optic 
nerve  and  retina  we  could  with  certainty  infer  what  was  going 
on  in  the  brain.  Thus  cerebroscopy  seemed  about  to  be 
established  as  a  new  branch  of  medical  science.  We  have 
learned  since  that  the  facts  do  not  warrant  such  enthusiastic 
views,  and  we  have  now  a  comparatively  clear  knowl- 
edge of  what  we  can  expect  from  ophthalmoscopic  and  other 
eye-symptoms  as  aids  to  the  diagnosis  of  brain  affections. 
There  remains  no  doubt  that  some  eye-symptoms  help  us 
to  diagnosticate  certain  intra-cranial  lesions,  and  they  are  some- 
times even  of  very  great  diagnostic  value.  In  a  few  cases  they 
may  even  enable  us  not  only  to  diagnosticate  an  intra-cranial 
affection,  but  also  to  locate  it. 

Without  going  further  into  anatomical  details  we  may  here 
state,  that  the  optic  nerve  and  retina  are  really  parts  of  the 
brain,  from  which  they  grow  during  foetal  life,  and  that  their 
blood-vessels  and  their  lymphatics  are  directly  connected  with 
those  of  the  brain.  Furthermore,  we  must  keep  in  mind  that 
the  sheaths  of  the  optic  nerve  are  directly  continuous  with  the 
meninges,  and  that  the  intervaginal  spaces  of  the  optic  sheaths 
correspond  to  and  are  in  direct  communication  with  the  spaces 
bounded  by  these  membranes  within  the  cranium. 

It  is  evident  from  these  anatomical  facts  that  an  increased  or 
diminished  supply  of  blood  or  lymphatic  fluid  in  the  brain 
and  cranial  cavity  must,  when  no  other  affections  exist,  cause 
a  like  condition  in  the  optic  nerve  and  retina. 

Although  these  facts  are  simply  due  to  the  mechanical  con- 
ditions and  cannot  be  doubted,  their  diagnostic  value  is  small- 

—257— 


258  OPHTHALMOLOGY. 

er  than  we  should  expect,  because  even  in  normal  eyes  the  in- 
dividual differences  in  the  number,  the  situation  and  th^  form 
of  the  bloodvessels  as  seen  with  the  ophthalmoscope,  are 
such  that  we  can  hardly  venture  to  diagnosticate  a  small  de- 
gree of  anaemia  or  hyperaemia,  unless  we  have  had  occasion  to 
examine  the  eyes  at  a  former  period.  Yet,  it  is  in  just  these 
cases  of  incipient  hyperaemia  and  anaemia,  that  the  diagnosis 
might  often  be  of  the  greatest  value. 

When,  however,  the  anaemia  or  hyperaemia  of  the  optic 
nerve  and  retina  have  reached  a  high  degree,  we  can  easily 
recognize  them,  and  thus,  in  combination  with  the  other  symp- 
toms present  in  the  case  before  us,  they  may  help  to  a  diag- 
nosis. 

If,  for  instance,  the  general  symptoms  lead  to  the  conclu- 
sion that  there  must  be  hyperaemia  of  the  brain,  a  pronounced 
hyperaemia  of  the  optic  nerve  and  retina  will  confirm  this  di- 
agnosis, if  all  other  causes  for  the  hyperaemia  of  these  parts 
can  be  excluded. 

Or,  if  we  find  in  an  otherwise  healthy  individual,  pronounced 
anaemia  of  the  optic  nerve  and  retina  (in  a  case  of  injury  to 
the  head,  for  instance),  the  diagnosis  of  anaemia  of  the  brain 
may  safely  be  made. 

In  other  cases  the  ophthalmoscopic  diagnosis  of  hyperaemia 
or  anaemia  of  the  optic  nerve  and  retina,  and  consequently  of 
the  brain  may  help  us  even  in  the  diagnosis  af  a  further  affec- 
tion. For  instance,  if  we  find  in  a  case  of  pertussis  (whoop- 
ing-cough) that  the  optic  nerve  and  retina  are  perfectly  anaem- 
ic, we  know  that  the  brain  is  also  anaemic,  and  this,  in  connec- 
tion with  the  knowledge  that  the  patient's  system  has  been 
greatly  reduced  by  the  disease,  may  help  us  to  the  conclusion 
that  the  heart's  action,  especially,  must  be  very  weak.  The  lat- 
ter is,  furthermore,  proved  by  the  fact  already  mentioned,  that 
by  paracentesis  of  the  anterior  chamber  and  the  consequent 
lowering  of  the  intraocular  tension,  we  can  bring  about  a  re- 
filling of  the  bloodvessels  of  the  optic  nerve  and  retina, 

§146.  Although  pronounced  hyperaemia,  or  anaemia  of  the 
optic  nerve  and  retina  must  necessarily  happen  quite  often,  we 
have  much  oftener  occasion  to  observe  and  to  utilize  for  diag- 


E  YES  YMP TOMS  IN  INTRA- CRANIAL  AFFECTIONS.        259 

nostic  purposes  certain  more  pronounced  changes  of  the  tis- 
sue, namely,  oedema  of  the  optic  papilla  and  optic  neuritis,  for 
the  reason  that  they  are  usually  combined  with  more  or  less 
important  disturbances  of  vision. 

Any  intra-cranial  affection  which  causes  an  increase  of  the 
intra-cranial  pressure  must  also  cause  an  increase  of  pressure 
in  the  intervaginal  spaces  of  the  optic  nerve.  This  increase  of 
pressure  will  lead  to  a  dropsical  distension  of  the  sheaths  of 
the  optic  nerv  near  its  entrance  into  the  eyeball  (See  Fig.  ill) 


Fig.  III. — Distention  of  the  intervaginal  space  of  the  optic  nerve  by  intracranial 
fluid  in  a  case  of  intracranial  tumor. 

with  venous  stasis  and  oedema  of  the  optic  papilla;  soon 
these  conditions  cause  inflammatory  symptoms,  first  in  the 
optic  papilla,  and  then  also  in  the  retinal  tissue.  Whenever, 
therefore,  we  find  neuro-retinitis  in  a  case  in  which  it  is  due  to 
an  increase  of  intracranial  pressure,  it  must  have  been  pre- 
ceded by  oedema  of  the  optic  papilla. 


Fig.  112. — Distention  of  the  intervaginal  space  by  organized  tissue,  the  result  of 
fibrino-plastic  exudation  driven  into  the  intervaginal  space  in  a  case 
of  meningitis. 

Neuritis  optica  may,  however,  furthermore,  be  caused  by  a 
fibrinous  or  fibrino-purulent  inflammation  of  the  sheaths  of 
the  optic  nerve  based  on  a  similar  form  of  meningitis.  This 
may  be   due  to   the    fact   that   an    exudation   resulting    from 


260  OPHTHALMOLOGY. 

meningitis  may  simply  be  forced  into  the  intervaginal  space 
of  the  optic  nerve  (See  Fig.  112),  or  the  inflammatory  process 
may  itself  spread  from  the  intracranial  meninges  to  those  of 
the  optic  nerve. 

The  result  of  these  inflammations,  as  we  have  seen  above,  is 
in  most  cases  the  total  atrophy  of  the  optic  nerve. 

CEdema  of  both  optic  papillae,  or  neuro-retinitis  in  both 
eyes,  give  us,  therefore,  generally  a  hint,  that  there  is  an  in- 
crease of  intracranial  pressure.  This  pressure  is,  however, 
of  little  further  diagnostic  value  (although  this  hint  alone  may 
under  some  circumstances  be  of  very  great  importance),  since 
intracranial  tumors,  haemorrhages,  abscesses,  and  encephalit- 
ic  and  meningitic  process  may  all  cause  these  symptoms  at  the 
ocular  end  of  the  optic  nerve.  Yet,  we  know  that  in  by  far 
the  largest  number  of  cases  these  symptoms  are  due  to  an  in- 
tracranial tumor,  and  this  fact,  together  with  the  general 
symptoms,  as  well  as  other  functional  troubles  which  may, 
perhaps,  exist  in  the  eye,  will  in  most  cases  help  to  make  the 
diagnosis  sure. 

The  diagnostic  value  of  the  condition  of  the  pupil  is  mainly 
confined  to  the  fact  that  paralysis  of  the  oculomotor  nerve  or 
irritation  of  the  sympathetic  nerve  cause  dilatation  of  the  pu- 
pil. Irritation  of  the  oculomotor  nerve  or  paralysis  of  the 
sympathetic  nerve  cause  contraction  of  the  pupil. 

§149.  A  subjective  eye-symptom  which  has  an  important 
bearing  on  the  localization  of  cerebral  affections  is  called  hemi- 
anopsia (half-blindness).  In  this  condition  one-half  the  visual 
field  of  one  or  both  eyes  is  wanting. 

When  examining  the  visual  field  of  an  eye  we  must  bear  in 
mind  that  the  nasal  half  of  the  visual  field  corresponds  to  the 
temporal  half  of  the  retina,  while  the  temporal  half  of  the 
visual  field  is  that  of  the  nasal  half  of  the  retina.  In  the  same 
manner  what  is  upwards  in  the  visual  field  is  perceived  by  the 
lower  parts  of  the  retina,  and  what  lies  downwards  in  the  vis- 
ual field  is  seen  with  the  upper  half  of  the  retina. 

The  diagnostic  value  of  hemianopsia  in  cerebral  lesions  is 
particularly  due  to  the  partial  decussation  of  the  optic  nerve 
fibres  when  forming  the  optic  chiasma. 


E  YES  YMP  TOMS  IN  INTRA-  CRANIAL  AFFE  C  TIONS.        261 

The  course  of  the  optic  nerve  fibres  in  man,  as  at  present 
accepted,  is  the  following: 

There  is  an  optic  center  in  the  occipital  lobe  of  each  half  of 
the  brain,  situated  in  the  cortex  more  particularly  in  the  region 
of  the  cuneus  and  near  the  gyrus  angularis.  From  here  the 
radiating  fibres  (of  Gratiolet)  go  forward  in  the  internal  capsule 
to  the  pulvinar  of  the  optic  thalamus,  are  joined  by  fibres  from 
the  corpora  quadrigemina  and  geniculata,  and  with  these  form 
the  tractus  opticus  of  each  half  of  the  brain.      When  the  two 


Fig.  113. — Shows  the  partial  decussation  of  the  fibres  of  the  optic  nerves  while  form- 
ing the  optic  chiasm.  (The  uncrossed  bundles  are  too  thin  in  this  draw- 
ing). The  lines  projecting  from  the  retina  to  the^horizontal  line  refer  to 
the  visual  fields. 

optic  tracts  reach  each  other  in  their  forward  course  the  optic 
chiasma  is  formed  by  the  partial  crossing  over  of  the  nerve 
fibres  of  the  right  hemisphere  to  the  retina  of  the  left  eye,  and 
of  the  fibres  of  the  left  hemisphere  to  the  retina  of  the  right  eye. 
This  partial  crossing  takes  place  in  such  a  manner  that  the 
crossed  bundle  from  the  right  tract  (about  two-thirds  of  the 
tract)  reaches  and  supplies  the  right  third  of  the  retina  of  the 
left  eye,  and  in  consequence  leads  to  the  optic  center  all  im- 
pressions perceived  in  the  left  portion  (half,  as  it  is  called)  of 
the  visual  field  of  the  left  eye.     (See  Fig.  113). 


262  OPHTHALMOLOG  K 

On  the  other  hand,  the  uncrossed  bundle  of  fibres  from  the 
right  optic  tract  goes  to  the  right  two-thirds  of  the  retina  of 
the  right  eye,  and  conveys  to  the  cortical  center  all  impres- 
sions received  in  the  left  portion  (half,  as  it  is  called)  of  the 
visual  field  of  the  right  eye. 

Thus,  the  crossed  bundle  from  the  left  optic  tract  sup- 
plies the  left  half  of  the  right  retina,  and  the  uncrossed  bun- 
dle the  left  half  of  the  left  retina  and,  of  course,  the  opposite 
parts  of  their  visual  fields. 

From  the  foregoing  it  is  apparent,  that  a  lesion  interfering 
with  the  perception  at  the  optic  center  itself  or  with  the  con- 
duction of  the  optic  fibres  in  one  side  of  the  brain,  during  their 
course  between  the  optic  center  and  the  chiasma,  will  cause 
partial  or  total  hemianopsia,  that  is,  loss  of  a  part  of  half  or 
the  whole  half  of  the  visual  field  on  the  opposite  side  in  both 
eyes. 

This  form  of  hemianopsia  is  the  most  frequently  observed 
one  and  it  is  called  bilateral  homonymous  hemianopsia  (right  or 
left  sided).     (See  Fig.  1 14). 

3  3 

Fig.  114. — Homonymous  (right-sided)  hemianopsia.    The  dark  parts  are  wanting  in 
the  visual  fields. 

Such  a  lesion  may  be  a  tumor,  an  abscess,  a  haemorrhage,  a 
trauma,  an  encephalitis  or  a  meningitis,  and  if  it  does  not  in- 
volve any  motor  or  sensory  area,  the  case  may  simply  present 
the  symptoms  of  hemianopsia.  If  the  lesion  lies  where  the 
optic  tract  lies  near  any  motor  or  sensory  centers  and  involves 
them  at  the  same  time,  symptoms  of  motor  or  sensory  paraly- 
sis or  paresis  or  perhaps  of  spasms  and  hyperaesthesia  may  be 
combined  with  the  hemianopsia. 


E  YES  YMP  TOMS  IN  IN  TEA-  CRANIAL  A  FEE  C  TIONS.        263 

Should  hemianopsia  be  combined  with  soul-blindness  alone 
we  might,  perhaps,  surmise  correctly  that  the  lesion  must  lie 
in  the  optical  center  in  the  occipital  lobe  where  Munk's  center 
is  also  located.  If  we  had  a  case  in  which  hemianopsia  would 
be  combined  with  paralysis  of  some  of  the  external  muscles  of 
the  eyeball,  we  should  probably  rightly  conjecture  a  lesion  at 
the  base  of  the  brain,  etc.  With  regard  to  the  diagnosis  of 
the  nature  of  the  lesion  in  all  these  cases  the  symptom  of 
hemianopsia  is,  of  course,  not  calculated  to  give  us  much  en- 
lightenment. 

Besides  the  bilateral  homonymous  hemianopsia,  cases  of  bi- 
lateral heteronymous  hemianopsia  and  unilateral  hemianopsia 
have  been  observed. 

Fig.  115. — Heteronymous  (in  this  case  "temporal")  hemianopsia.     The  dark,  outer, 
halves  are  wanting  in  the  visual  fields. 

Bilateral  heteronymus  hemianopsia  is  either  temporal  or  na- 
sal. The  temporal  form  must  be  due  to  a  lesion  encroaching 
upon  the  anterior  commissure  of  the  chiasma,  that  is  the 
crossed  bundles  of  the  optic  nerve  fibres.  (See  Fig  115).  If 
the  lesion  only  affects  the  crossed  bundle  of  one  side  unilat- 
eral temporal  hemianopsia  must  result. 

Nasal  bilateral  hemianopsia  can  only  be  due  to  a  lesion 
which  involves  both  lateral  commissures  of  the  chiasma,  that 
is,  the  uncrossed  bundles  of  the  optic  nerve  fibres. 


CHAPTER    XXIIL— DEVELOPMENT    OF    THE    EYE 
AND    CONGENITAL    MALFORMATIONS. 

§150.  The  time  when  the  formation  of  the  eye  begins  is 
not  estabhshed  for  man.  It  seems,  however,  that  it  takes 
place  between  the  third  and  fourth  week. 


Fig.  116. — Primary  ocular  vesicle  springing  from  the  first  cerebral  vesicle  on  the 
right. 

The  first  sign  of  the  formation  of  the  eye  is  a  small  protru- 
sion of  the  lateral  wall  of  the  first  cerebral  vesicle.  (See  Fig. 
1 16).  This  protrusion  is  called  the  primary  ocular  vesicle.  The 
primary  ocular  vesicle  is  covered  by  mesoderm  and  ectoderm. 
The  ectoderm  at  the  height  of  the  primary  vesicle  begins  soon 
to  grow  thicker  and  convex  towards  the  inner  side.  As  it 
grows  an  indentation  results  at  first  in  the  primary  vesicle 
and  gradually  as  the  ectoderm  grows  farther  and  farther  in- 
ward, the  secondary  ocular  vesicle  is  formed  by  the  re-duplica- 
tion of  the  primary  vesicle.  (See  Fig.  117).  During  this  pe- 
riod the  ocular  vesicle  is  gradually  farther  removed  from  the 
cerebral  vesicle  and  the  communication  between  the  two,  at 
first  quite  wide,  grows  narrower  and  longer.      In   this   hollow 

—264— 


DEVELOPMENT  OF  THE  EYE.  265 

pedicle  later  on  the  optic  nerve  is  formed.  The  swelling  ecto- 
derm by  which  the  formation  of  the  secondary  ocular  vesicle  is 
brought  about  is  in  the  beginning  open  toward  the  surface. 
Gradually  this  opening  is  closed  and  the  sack  so  formed  filled 
with  ectodermic  elements,  is  later  on  the  crystalline  lens.  It  is 
now  covered  by  mesoderm  and  ectoderm.  During  this  period 
the  ocular  vesicle  has  an  opening  on  the  lower  side  in  the 
shape  of  a  deep  furrow,  Xh^  foetal  ocular  fissure.     Through  this 


Fig.  117. — Secondary  ocular  vesicle.      Beginning  of  the  formation  of  the  crystalline 
lens. 


fissure,  which  extends  back  into  what  is  later  on  the  optic 
nerve,  mesoderm  enters  between  the  lens  and  the  ocular  vesi- 
cle and  forms  the  vitreous  body,  which  is  soon  filled  with 
bloodvessels.  Meanwhile  the  two  layers  of  the  ocular  vesicle 
have  changed  in  such  a  manner  that  the  external  layer  has 
become  thin  and  pigmented,  while  the  inner  layer  has  grown 
quite  thick.  (See  Fig.  118).  The  outer  layer  forms  the  pig- 
mented epithelium,  the  inner  layer  the  retina.  bloodvessels 
appear  in  the  mesoderm  surrounding  the  whole  ocular  vesicle. 
They  form  the  choroid  in  the  posterior  parts,  and  in  front  of 
the  crystalline  lens,  the  vascular  pupillary  membrane.  Finally 
sclerotic  and  cornea  become  differentiated.  The  ciliary  body 
and  iris  grow  toward  the  axis  of  the  eye  from  the  part  where 
the  external  layer  of  the   primary  ocular  vesicle   is  folded  in- 


266 


OPHTHALMOL  OGY. 


ward  to  form  the  secondary  vesicle.  The  fcetal  ocular  fissure 
closes  in  the  eyes  of  mammals  at  the  beginning  of  the  second 
month. 


Fig.  ii8. — The  outer  portion  of  the  ocular  vesicle  forms  the  pigment  epithelium,  the 
inner  one  the  retina.  The  crystalline  lens  lies  in  front  of  it.  Between 
the  retina  and  crystalline  lies  the  vascular  vitreous  body.  The  blood- 
vessells  surrounding  the  ocular  vesicle  form  the  choroid  and  the  mem- 
brana  pupillaris.     (After  J.  Arnold). 

The  bloodvessels  in  the  vitreous  body  come  from  the  arteria 
hyaloid ea,  a  branch  of  the  central  retinal  artery.  This  larger 
bloodvessel  runs  forward  through  the  vitreous  body  (canal  of 
Cloquet)  to  the  posterior  surface  of  the  crystalline  lens  [mem- 
brana  capsularis). 

These  bloodvessels,  as  well  as  those  in  front  of  the  crystall- 
ine lens  (membrana  pupillaris)^  disappear  in  about  the  sixth 
month  or  later. 


§151.     The  eyes  and  their  adnexa  are  not   unfrequently  the 
seat  of  congenital  malformations.      These  may  affect  only  one 


CONGENITAL  MALFORMATIONS.  267 

eye  or  both  and  may  be  due  to  faulty  development,  to  arrest 
of  development,  or  to  diseases  during  foetal  life,  or  they  may 
be  caused  by  the  persistence  of  parts  which,  though  playing  an 
important  role  during  the  development  of  the  eye,  have  usu- 
ally undergone  retrogressive  metamorphosis  and  and  have  dis- 
appeared before  birth.  The  anomalies  concerning  the  whole 
eyeball  or  several  parts  of  it,  due  to  arrest  of  development  are 
dependent  in  the  main  on  the  too  early  or  too  late  and  insuffi- 
cient closure  of  the  foetal  fissure  and  date,  therefore,  back  to 
an  early  period  of  foetal  existence.  Anomalies  concerning  the 
iris,  lens,  or  cornea  alone,  and  the  adnexa  of  the  eye  are  usu- 
ally formed  at  a  later  date  of  the  development  of  the  foetal 
eye. 

§152.  The  most  frequent  malformation  which  concerns  the 
whole  eyeball  is  that  it  is  relatively  too  small  {microphthalmus)\ 
this  is  often  combined  with  other  anomalies,  as  microcornea^ 
coloboma  of  the  iris  or  of  the  iris  and  choroid,  cataract  and  dis- 
location of  the  crystalline  lens.  It  mostly  concerns  both  eyes. 
While  vision  in  some  cases  is  very  good,  in  others  it  is  but 
poor.  In  a  great  number  of  cases  it  has  been  seen  combined 
with  ptosis,  probably  due  to  the  smallness  of  the  eyeball  which 
renders  the  action  of  the  levator  much  less  efficient. 

§153.  Sometimes  one  or  both  eyeballs  are  considerably  too 
large,  megalophthalmus  {buphthalmus,  hydrophthalmus).  In 
this  malformation  the  vitreous  body  is  not  gelatinous  but  fluid, 
and  the  intraocular  pressure  is,  or  was  at  one  time,  considerably 
above  the  normal.  Sometimes  the  anterior  chamber  and  cornea 
(megalocorneay  cornea  globosd)  are  more  especially  increased  in 
size  {hydrophthalmus  anterior).  The  cornea  in  these  cases 
may  be  perfectly  transparent,  or  it  shows  partial  dimness.  The 
iris  is  usually  discolored  and  atrophied,  and  trembles  when  the 
eye  is  moved.  In  the  latter  case  the  suspensory  ligament  is 
stretched,  or  has  given  way  in  some  portion,  and  the  crystall- 
ine lens  is  partially  dislocated. 

The  cornea  is  sometimes  the  seat  of  congenital  leucoma 
without  any  other  malformation.  Sometimes  its  shape  is  that 
of  a  cone  {keratoconus,  conical  cornea).   (See   Fig.  48,  Chapter 


268  OPHTHALMOL  OGY. 

VIII).  At  the  periphery  of  the  cornea  we  sometimes  meet 
with  a  small  roundish  tumor  bearing  hair,  and  consisting  of  the 
tissues  of  the  skin  [dermoid). 

§154.  Sometimes  the  iris  is  totally  absent  or  nearly  so  (ani- 
ridia, iridemia).  In  other  cases  only  a  sector  of  the  iris  is 
wanting  (coloboma  iridis).  (See  Fig.  119).  This  sector  is 
usually  wanting  in  the  lower  half  of  the  iris,  the  region  of  the 
foetal  fissure.  The  coloboma  may  reach  further  back  into  the 
ciliary  body  and  choroid,  retina  and  optic  nerve.  Such  colo- 
bomata  have  also  been  found  in  the  crystalline  lens  and  the 
vitreous  body.  It  is,  furthermore,  most  likely  that  the  poste- 
rior staphyloma  (staphyloma  of  Scarpa)  in  myopic  eyes  has 
its  origin  also  in  an  insufficient  closure  of  the  foetal  fissure. 
Its  position  can,  however,  only  be  explained  by  a  rotation  of 
the  foetal  eyeball  around  its  axis. 


Fig.  119. — Congenital  coloboma  of  the  iris. 

Sometimes  the  pupil  is  found  to  lie  excentrically  (korectopid). 
Remnants  of  the  foetal  pupillary  membrane  are  found  quite 
frequently.  They  may  be  small  threads  hanging  from  the  an- 
terior surface  of  the  iris  into  the  pupillary  area,  or  such  threads 
may  cross  over  the  pupil  from  one  side  of  the  iris  to  the  dia- 
metrically opposite  one.  (See  Fig.  120).  When  these  remnants 
are  broader  bands  of  tissue  and  anastomose  with  each  other  in 
the  pupillary  area  they  may  divide  it,  so  to  speak,  into  several 
pupils  {polykoria),  and  as  many  as  five  such  pupils  and  even 
more  have  been  observed  in  one  eye. 


CONGENITAL  MALFORMATIONS. 


269 


§155.    Another  remnant  of  foetal  life,  the  arteria  hyaloidea^  is 
not  rarely  found.     It  appears  as  a   string   of  abnormal   tissue 


Fig.  120. — Persistent  remains  of  the  fcaetal  pupillary  membrane. 

attached  to  the  optic  papilla  and   reaching  into   the   vitreous 
body,  sometimes  as  far  forwards  as  the  posterior  surface  of  the 


Fig.  121. — Congenital  coloboma  of  the  choroid. 

crystalline  lens.  According  to  its  size  and  the  excursions  it 
makes  during  the  movements  of  the  eyeball,  it  may  interfere 
considerably  with  vision. 


270  OPHTHALMOLOGY. 

The  optic  nerve  is  sometimes  but  partially  developed  or  it  is 
atrophic.  Very  frequently  we  find  that  the  change  of  med- 
ullated  nerve  fibres  into  non-medullated  ones  takes  place  in  the 
retina  near  the  optic  papilla,  instead  of  taking  place  during 
the  passage  of  the  optic  nerve  through  the  sclerotic. 

In  rare  cases  congenital  atrophic  spots  are  found  in  the  cho- 
roid, or  a  coloboma  of  the  choroid  alone.     (See  Fig.  121). 

The  congenital  malformations  of  the  crystalline  lens  have 
already  been  spoken  of. 


Fig.  122. — (After  Manz).     Congenital  coloboma  of  the  eyelids  with  adhesion  be 
tween  the  upper  eyelid  and  the  cornea. 

§156.  Coloboma  of  the  eyelids  has  sometimes  been  observ- 
ed and  has  been  usually  found  to  be  combined  with  symbleph- 
aron,  a  piece  of  skin  from  the  upper  lid  being  attached  to  the 
cornea.  (See  Fig.  122).  Total  lack  of  the  eyelids,  or  a  con- 
dition in  which  the  skin  passes  uninterruptedly  over  the  exter- 
nal orifice  of  the  orbit  and  covers  the  usually  deformed  eyeball 
(kryptophthalmus),  has  been  seen  by  several  observers. 

Congenital  symblepharon  and  ankylopharon  are  rare.  A 
more  frequent  affection  is  ptosis  of  the  upper  eyelid.  In  these 
cases  the  levator  palpebrae  superioris  is  either  badly  developed 
or  totally  wanting. 

Epicanthus  internus,  a  malformation  which  is  often  combined 
with  ptosis  of  the  upper  lid  and  strabismus  convergence  (See 
Fig.  123),  is  usually  found  to  affect  both  sides,  and  consists  of 
a  semilunar  fold  of  skin,  with  its  concavity  towards  the  eyes, 
which  connects  the  upper  and   lower  lids  at   their   nasal  side. 


CONGENITAL  MALFORMATIONS. 


271 


The  position  of  the  lachrymal  caruncle  and  lachrymal  papillae 
is  not  influenced  by  it.  In  rare  cases  epicanthus  has  been 
seen  on  the  temporal  side  [epicanthus  externus). 


Fig.  123. — (After  Von  Ammon).     Epicanthus  internus  with  strabismus  convergens. 

The  anomalies  of  the  lachrymal  apparatus  are  mostly  ab- 
sence of  one  or  both  lachrymal  puncta  or  supernumerary 
puncta. 

A  number  of  congenital  tumors  are  found  in  the  adnexa  of 
the  eye.  They  are  either  cysts  or  vascular  tumors  of  the  orbit- 
al tissue  and  eyelids. 

A  congenital  lack  of  pigment  in  the  uveal  tract,  usually 
combined  with  lack  of  pigment  of  the  hair,  is  known  as  al- 
binism. 

In  rare  cases  the  iris  of  one  eye  is  differently  colored  from 
that  of  the  fellow-eye,  or  we  see  in  one  and  the  same  iris 
patches  or  sectors  differing  in  color  from  the  rest  (heterophthal- 
muSy  heterochromia). 


CHAPTER      XIV.— EYE-AFFECTIONS     DEPENDENT 
ON   DISEASES  OF  OTHER  ORGANS  OR 
DISEASES    OF    THE     GENERAL 
SYSTEM. 

§157.  Respiratory  apparatus. — In  affections  of  the  respira- 
tory apparatus,  which  cause  a  great  deal  of  hard  coughing, 
and  especially  in  whooping  cough,  the  rupture  of  a  conjuncti- 
val bloodvessel  is  sometimes  observed.  The  resultant  ecchy- 
mosis  may,  of  course,  vary  greatly  in  size.  No  special  treat- 
ment is  required.  The  same  thing  may  happen  during  an 
attack  of  forcible  sneezing. 

Catarrhal  inflammation  of  the  mucous  membrane  of  the  nose 
may  extend  into  the  nasal  duct  and  there  cause  a  swelling  and 
obstruction,  and  thus  give  rise  to  stillicidium  (tear-dropping). 
If  the  case  is  an  acute  one,  the  symptoms  in  the  tear-duct 
may  pass  away  with  it.  In  chronic  catarrh  of  the  nasal  mucous 
membrane,  the  nasal  duct  becomes  frequently  permanently  ob- 
structed by  scar-tissue,  or  by  disease  of  the  bones,  due  to  the 
diathesis  upon  which  the  chronic  nasal  catarrh  is  based  (syph- 
ilis and  scrophulosis).  In  the  treatment  of  these  cases  a  care- 
ful examination  of  the  nose  must  not  be  forgotten,  and  often 
the  lachrymal  trouble  cannot  be  cured  until  the  nasal  mucous 
membrane  is  brought  back  to  the  normal  condition. 

Hypertrophic  rhinitis,  which  is  known  to  cause  a  number  of 
reflex  symptoms,  may  also  produce  reflex  symptoms  in  the 
eyes,  particularly  a  form  of  asthenopia  which  might  be  termed 
nasal  asthenopia.  It  is,  however,  more  frequently  the  cause 
of  lachrymal  conjunctivitis. 

Ozcena  may  give  rise  to  infectious  ulcers  of  the  cornea. 
Phyctaenular  keratitis,  blepharitis  and  follicular  conjunctivitis 
may  be  due  to  infection  from  the  nasal  secretions. 

Tumors  of  the  nose^  polypi  of  a  benign  or  malignant  char- 
acter, are  apt  to  encroach  upon  the  orbit,  and  thus  can  cause 
exophthalmus. 

—272- 


EYE-AFFECTIONS  IN  OTHER  DISEASES.  273 

§158.  Circulatory  apparatus. —  Diminished  arterial  pressure, 
especially  when  caused  by  the  insufficiency  of  the  aortic  valves, 
may  cause  pulsation  of  the  arteries  of  the  retina;  this  pulsa- 
tion is  isochronous  with  the  systolic  contraction  of  the   heart. 

If  the  force  of  the  heart's  action  is  considerably  reduced, 
this  may  cause  ischaemia  of  the  optic  nerve  and  retina.  The 
heart  in  such  cases  is  no  longer  able  to  overcome  the  normal 
intraocular  tension,  but  it  can  do  so  again  when  the  tension 
is  reduced  by  paracentesis  of  the  anterior  chamber. 

Pernicious  progressive  ancBmia  causes  anaemia  of  the  optic 
papilla  and  retina,  accompanied  by  numerous  haemorrhages 
into  the  retinal  tissue. 

Hypertrophy  of  the  left  ventricle  of  the  heart  is  apt  to  pro- 
duce retinal  haemorrhages,  or  haemorrhages  into  the  vitreous 
body,  and  this  may  happen,  whether  the  venous  stasis  is  due 
originally  to  an  affection  of  the  lungs  or  of  the  heart. 

Fibrinous  endocarditis  may  be  the  cause  of  an  embolism  of 
the  central  retinal  artery  or  of  one  of  its  branches. 

Pulsating  exophthalmus  is  a  symptom  which  in  almost  all 
cases  is  due  to  an  affection  of  the  bloodvessels,  and  but  very 
rarely  to  a  pulsating  tumor  of  the  orbit.  Its  most  prominent 
symptom  is  the  exophthalmus,  which  is  often  one-sided,  and 
may  be  very  considerable.  The  upper  eyelid  is  swollen,  and 
its  veins  are  dilated,  and  the  conjunctiva  shows  dilated  blood- 
vessels and  serous  infiltration.  The  pupil  it  generally  dilated. 
The  eyeball  can  be  pressed  into  the  orbit  without  causing  pain, 
but  it  will  protrude  again  as  soon  as  the  pressure  is  released. 
When  the  fingers  are  placed  on  the  eyeball,  it  is  felt  to  pulsate. 
Sometimes  this  pulsation  is  even  visible.  By  auscultation  pul- 
satory sounds  are  heard  on  the  eye  and  the  surrounding  re- 
gions. Compression  of  the  common  carotid  artery  reduces 
these  sounds  or  stops  them  altogether. 

This  exophthalmus  may  be  accompanied  by  optic  neuritis  or 
oedema  of  the  optic  papilla.  The  retinal  veins  are  always  con- 
siderably enlarged  and  pulsate.  Sight  may  be  very  much  im- 
paired, and  in  some  cases  blindness  has  been  observed.  The 
patients  complain  chiefly  of  the  continued  noise,  and  some- 
times of  pain.  Paresis  of  the  external  muscles  of  the  eyeball 
may  cause  diplopia.     These  symptoms  have  but   very   seldom 


274  OPHTHALMOLOGY, 

come  on  without  any  known  cause;  in  most  cases  they  have 
developed  after  an  injury,  and  for  the  most  part  after  a  heavy 
fall.  They  may  follow  rapidly  upon  the  injury,  which  is  the 
rule,  or  they  may  develop  more  slowly.  When  the  exoph- 
thalmus  occurs  in  both  eyes,  one  eyeball  usually  has  protruded 
before  the  other. 

In  a  few  cases  the  patients  have  been  known  to  recover  spon- 
taneously from  this  affection,  but  in  most  cases,  when  not  in- 
terfered with,  death  has  been  the  result.  The  cases  of  idio- 
pathic pulsating  exophthalmus  seem  to  be  more  frequent 
among  women,  while  the  traumatic  ones  have  nearly  all  oc- 
curred in  men  {Saltier). 

The  anatomical  cause  of  pulsating  exophthalmus  is  some- 
times an  aneurysm  of  the  ophthalmic  artery,  but  in  a  large 
majority  of  the  cases  a  rupture  of  the  internal  carotid  within 
the  cavernous  sinus,  with  consequent  effusion  of  arterial  blood 
into  this  sinus  and  increase  of  blood  pressure,  causing  dilata- 
tion of  the  superior  ophthalmic  vein,  and  ultimately  of  all  the 
venous  vessels  communicating  with  the  superior  ophthalmic 
vein,  and  also  of  the  inferior  ophthalmic  vein.  The  central 
retinal  vein,  which  empties  the  blood  either  into  the  superior 
ophthalmic  vein  or  directly  into  the  cavernous  sinus,  soon 
shows  therefore  the  same  symptoms  of  dilatation  and  pulsa- 
tion. 

The  therapeutic  measures  must,  of  course,  be  directed  to 
the  primary  affection.  As  this  is  usually  a  rupture  of  the  in- 
ternal carotid  artery,  continuous  digital  compression  or  liga- 
tion of  the  common  carotid  artery  must  be  performed. 

We  may  here  refer  also  to  amblyopia,  or  amaurosis  depend- 
ant on  the  loss  of  large  quantities  of  blood,  to  whatever  cause 
it  may  be  due,  such  as  wounds,  ulcers  of  the  stomach,  the  can- 
cerous erosion  of  a  larger  bloodvessel,  intestinal  haemorrhages, 
uterine  affections,  etc.  If  the  patient  recovers  from  the  loss 
of  blood,  his  sight,  as  a   rule,  will  also    gradually  be  regained. 

§159.  Organs  of  Digestion. — The  congestion  to  the  head 
caused  by  chronic  constipation,  and  by  hyperaemia  of  the  liver, 
is  sometimes  combined  with  eye-symptoms.  These  are,  in  the 
main,  an  easily  fatigued  accommodation,  and  the    appearance 


EYE-AFFECTIONS  IN  OTHER  DISEASES,  275 

of  dark  or  light  spots  dancing  before  the  eyes.      These  symp- 
toms disappear  with  the  removal  of  their  primary  cause. 

Leukceniia  causes  a  form  of  retinitis  which  is  said  to  be  char- 
acterized by  a  yellow  tint  of  the  whole  retina. 

§i6o.  Uro-poetic  Apparatus. — Diseases  of  the  kidneys  give 
rise  to  various  eye  affections.  The  affection  which  we  call 
albuminuric  neuro-retinitis,  and  which  has  been  already  de- 
scribed in  Chapter  XIII,  is  generally  due  to  the  shrinking  kid- 
ney, that  form  of  nephritis  in  which  the  specific  gravity  of  the 
urine  is  usually  low,  and  in  which  the  albumen  is  small  in 
quantity,  or  may  at  times  be  wanting  altogether.  Albumin- 
uric retinitis  is  also  found  in  acute  croupous  nephritis,  as  dur- 
ing scarlet  fever,  and  in  cases  of  amyloid  degeneration  of  the 
kidneys.  The  disease  of  the  kidneys  may  lead  to  albumin- 
uric retinitis  by  causing  an  abnormal  condition  of  the  blood, 
which  brings  on  pathological  changes  in  the  coats  of  the  blood- 
vessels. Further  symptoms  may  be  due  to  increased  blood- 
pressure  and  to  the  retention  of  urea.  Although  this  form  of 
retinitis  belongs,  as  a  rule,  to  the  latter  stages  of  the  kidney 
disease,  it  is  sometimes  the  first  symptom  noticed  by  the  pa- 
tient; and  its  characteristic  features  may  thus  sometimes  lead 
us  to  detect  a  kidney  disease  when  no  other  symptom  is  as  yet 
so  pronounced  as  to  suggest  the  diagnosis. 

Another  eye  affection  due  to  kidney  disease  is  the  so-called 
urcemic  amaurosis.  It  is  seen  in  all  forms  of  nephritis,  but 
chiefly  in  acute  nephritis  from  scarlet  fever  or  the  nephritis  of 
pregnant  women.  The  blindness  usually  comes  on  rapidly 
during  an  uraemic  attack.  The  pupils  are  sometimes  dilated. 
Whether  the  patient  has  already  been  suffering  from  albumin- 
uric retinitis  or  not,  makes,  of  course  no  difference  as  regards 
the  occurrence  of  such  a  uraemic  amaurosis.  The  amaurosis 
may  pass  off  again  aVter  a  few  hours.  Sometimes,  however,  it 
lasts  even  several  days. 

Albuminuric  neuro-retinitis  occurs,  also,  as  a  symptom  of 
nephritis  of  pregnancy.  It  is  then  a  very  grave  symptom  and 
an  indication  for  bringing  about  premature  labor. 

§i6r.     Genital  organs, — Amblyopia  is  sometimes  seen  after 


276  ^  OPHTHALMOLOGY. 

excesses  in  venere.  It  never  lasts  long  in  these  cases,  and 
does  not  give  rise  to  a  serious  affection.  Onanism,  especially 
when  frequently  indulged  in,  causes  the  same  symptoms.  It 
has  become  to  be  quite  an  accepted  fact  that  onanism,  as  such 
may,  and  is  likely  to  lead  to  serious  eye  affections,  and  it  fre- 
quently happens  that  a  patient  comes  to  the  physician  fright- 
ened out  of  his  wits  after  having  read  about  the  serious  con- 
sequences of  this  habit.  An  examination  either  reveals  no 
eye  affection  at  all,  or  one  which  has  nothing  to  do  with  the 
self-indulgence,  and  which  in  all  probability  has  existed  pre- 
viously. 

We  may  in  this  place  speak  also  of  a  disease  in  which  the 
eye-symptoms  are  very  prominent,  and  which  by  many  is 
thought  to  be  due  to  an  affection  of  the  genital  organs.  I  re- 
fer to  exophthalmic  goitre,  or  Basedow's  {Graves')  disease. 

The  cardinal  symptoms  of  Basedow's  disease  are  an  increas- 
ed action  of  the  heart,  exophthalmus  of  one  or,  generally,  of 
both  eyes,  and  goitre,  although  one  of  these  three  symptoms 
may  be  wanting. 

The  first  symptom  is  generally  the  increased  heart's  action. 
The  pulse  ranges  from  lOO  to  200  in  the  minute,  the  shock  at 
the  apex  of  the  heart  is  felt  much  stronger  than  in  the  normal 
condition  and  can  even  be  seen,  although  the  heart  is  usually 
not  hypertrophic.  The  carotid  arteries  and  the  veins  of  the 
neck  pulsate  visibly.  Any  excitement  or  tiresome  work  ag- 
gravates these  symptoms.  Sooner  or  later  the  thyrioid  gland 
begins  to  swell.  The  tumor  is  at  first  soft,  but  later  on  it  be- 
comes harder  in  conseqence  of  the  newformation  of  connective 
tissue  or  of  deposits  of  lime  within  it.  The  swelling  is  at  first 
not  very  large,  and  it  may  come  and  go.  With  the  hand  a 
tremor  may  be  felt  over  the  thyrioid  gland,  and  with  the  steth- 
oscope circulatory  murmurs  can  be  heard  in  it.  The  exoph- 
thalmus appears  usually  as  the  last  of  the  three  cardinal 
symptoms.  The  protrusion  of  the  eyeballs  is  mostly  in  a 
forward  direction,  but  sometimes  there  is  divergent  strabismus. 
In  most   cases  the  protrusion  occurs  in  both  eyes. 

Combined  with  the  exophthalmus  is  a  loss  ot  co-ordination 
in  the  movements  of  the  eyeball  and  eyelids,  so  that  in  down- 
ward movements  of  the   eyes  the  upper  lids   lag  behind  and 


EYE-AFFECTIONS  IN  OTHER  DISEASES,  277 

expose  a  strip  of  the  sclerotic.  In  the  lower  eyelids  the  same 
symptom  is  present,  but  it  is  less  noticeable.  This  symptom 
{Graefe's)  is  considered  as  almost  pathognomonic  for  this  form 
of  exophthalmos,  and  it  is  sometimes  observed  even  before  the 
exophthalmus  has  become  very  conspicuous.  The  palpebral 
fissure  is  generally  very  wide,  and  involuntary  nictitation  is 
wanting. 

The  pupils  are  often  normal,  in  other  cases  dilated,  the  ac- 
commodation remains,  however,  undisturbed.  The  secretion  of 
tears,  at  first  increased,  becomes  later  on  diminished,  and  a 
conjunctival  catarrh  is  seldom  entirely  wanting.  The  cornea 
becomes  dry,  since  the  eyelids  do  not  protect  it  properly,  and 
ulcerations,  even  the  total  destruction  of  the  cornea,  may  be 
the  result.     The  retinal  arteries  pulsate. 

These  cardinal  symptoms  are  attended  by  a  number  of  vary- 
ing ones,  as  chlorosis  or  anaemia,  uterine  affections,  higher 
temperature,  etc.  The  palpitations  of  the  heart  cause  disp- 
noea,  orthopncea,  and  even  angina  pectoris.  The  digestion  is 
disturbed.  Headache  and  insomnia  are  almost  constant  symp- 
toms, and  help  to  lower  the  vital  power. 

Basedow's  disease  rarely  appears  as  an  acute  affection,  and 
it  usually  takes  several  years  for  all  its  symptoms  to  become 
fully  developed.  Intermissions  are  the  rule,  and  the  charac- 
teristic symptoms  of  the  disease  may  even  exist  for  years,  and 
then  disappear.  In  about  12  per  cent,  of  the  cases  {von  Dusch) 
death  results  from  exhaustion,  from  ascites,  haemorrhages  into 
the  brain,  lungs  or  intestinal  tract. 

The  diagnosis  is  easy  when  the  cardinal  symptoms  are  all 
well  marked.  In  the  beginning,  however,  the  disease  might 
be  confounded  with  paralysis  of  the  sympathetic  nerve. 

According  to  Mooren,  Basedow's  disease  attacks  twelve  wom- 
en to  one  man.  It  develops  often  after  other  severe,  weaken- 
ing diseases,  great  losses  of  blood,  undue  bodily  exertion,  etc. 
Sometimes  it  seems  to  be  dependent  on  an  hereditary  tenden- 
cy, and  may  show  itself  in  several  members  of  the  same  fam- 
ily. 

Anatomical  examinations  have  shown  that  the  heart  in  Base- 
dow's disease  may  be  actually  dilated  and  hypertrophied.  The 
goitre  is  most  frequently  a  glandular  hypertrophy,  but  in  some 


278  OPHTHALMOLOGY. 

cases  it  has  been  found  to  be  simply  due  to  a  dilatation  of  the 
bloodvessels  of  the  thyrioid  gland.  The  orbital  fat  is  usually 
hypertrophic  and  oedematous,  and  its  bloodvessels  are  dilated. 
The  external  muscles  of  the  eye  have  been  found  in  a  state 
of  fatty  degeneration,  but  in  a  single  case  which  I  had  occa- 
sion to  examine,  they  were  normal.  Change  of  various 
kinds  in  the  cervical  part  of  the  sympathetic  nerve  and 
its  ganglia  have  been  reported  in  some  cases;  in  other 
cases  no  such  changes  could  be  detected.  Pathological  anat- 
omy has,  therefore,  thus  far  revealed  no  common  cause  for  all 
the  symptoms  observed  in  Basedow's  disease,  and  it  is  only 
upon  the  clinical  symptoms  that  any  rational  explanation  can 
be  founded. 

The  palpitations  of  the  heart  may  be  due  to  irritation  of  the 
excito-motory  nerves  of  the  heart,  which  arise  from  the  medul- 
la oblongata,  enter  the  sympathetic  nerve  and  leave  it  again 
with  branches  forming  the  cardiac  plexus,  or  they  may  be  due 
to  paralysis  of  the  inhibitory  nerve-fibres  coming  from  the  va- 
gus nerve. 

Paralysis  of  the  cervical  part  of  the  sympathetic  nerve  will 
account  for  the  vascular  symptoms  in  Basedozv's  disease,  the 
goitre  and  even  the  exophthalmus;  but  it  produces  contraction 
of  the  pupil  and  of  the  palpebral  fissure,  while  by  irritation  of 
the  oculo-pupillary  fibres  of  the  cervical  part  of  the  sympa- 
thetic nerve,  which  spring  from  the  anterior  root  of  the  second 
dorsal  nerve,  we  can  produce  widening  of  the  palpebral  fissure, 
dilatation  of  the  pupil  and  exophthalmus.  We  should,  there- 
fore, have  to  accept  two  different  conditions  in  the  tract  of  the 
same  nerve  in  order  to  explain  the  more  prominent  spmptoms 
of  Basedow  s  disease  on  the  hypothesis  of  an  origin  in  the 
sympathetic  nerve. 

It  would  be  going  too  far  to  give  here  all  theories  which 
have  been  advanced  in  order  to  explain  the  symptoms  of  this 
disease.  Suffice  it  to  say,  that  paralysis  of  the  center  for  the 
vagus  nerve  explains  best  the  majority  of  the  symptoms  when 
combined  with  paralysis  of  a  special  (assumed)  center  for  the 
bloodvessels  of  the  orbit  and  thyrioid  gland,  and  of  the  reflex- 
center  for  the  movements  of  the  eyehds.  From  this  fact  it 
appears  that  the  symptoms  of  Basedow's  disease  are  due  to  a 


EYE-AFFECTIONS  IN  OTHER  DISEASES,  279 

brain  lesion  and,  in  fact,  Filehne,  by  cutting  into  the  corpora 
restiformia  of  rabbits  without  injuring  the  fourth  ventricle,  after 
having  first  severed  the  sympathetic  nerve,  has  produced  the 
cardinal  symptoms  of  this  disease. 

Tonic  treatment  of  all  sorts  has  been  recommended  in  this 
affection.  The  most  successful  treatment  seems  to  be  galvani- 
zation, combined  with  strophantus,  or  arsenic  and  iron  inter- 
nally. 

If  the  cornea  is  endangered  by  ulceration,  the  palpebral  fis- 
sure may  be  shortened  by  tarsorraphy. 

§162.  Affections  of  the  skin. — Erysipelas  of  the  face  has  in 
several  cases  led  to  thrombosis  of  the  central  retinal  vein  and 
atrophy  of  the  optic  nerve  through  compression,  consequent 
on  the  extension  of  the  inflammation  to  the  orbital  tissues. 

Herpes  zoster  is  sometimes  found  together  with  herpes  of  the 
cornea,  and  the  latter  is  then  considered  to  be  due  to  a  disease 
of  the  ganglion  Gasseri. 

§163.  Infectious  Diseases. — Measles  in  the  eruptive  stage 
give  rise  to  conjunctivitis.  Chronic  conjunctivitis  conjoined 
with  blepharitis  ciliaris,  and  phlyctaenulae,  and  even  parenchy- 
matous keratitis,  are  often  seen  after  measles,  and  their  occur- 
rence may  be  due  to  the  lowering  of  the  whole  system  by  this 
disease,  or  to  direct  infection.  Optic  neuritis  and  amaurosis 
have  also  been  observed  after  measles,  but  they  are  extremely 
rare. 

Scarlet  fever,  by  causing  nephritis,  may  bring  about  an  albu- 
minuric neuro-retinitis,  or  a  uraemic  amaurosis.  Diphtheria  of 
the  conjunctiva  may  be  seen  in  combination  with  scarlet  fever. 

Small'pox  may  give  rise  to  a  great  variety  of  eye-affections, 
not  counting,  of  course,  the  fact  that  pustules  may  be  located 
on  the  skin  of  the  eyelids. 

Catarrhal,  purulent,  and  diphtheritic  conjunctivitis,  keratitis, 
blennorrhcea  of  the  lachrymal  sack,  iritis  and  choroiditis  are 
often  observed  during  and  after  this  disease.  The  most  fre- 
quent affections,  however,  are  those  of  the  conjunctiva  and 
cornea.  The  corneal  troubles  have  also  been  observed  to  de- 
velop some  weeks  after  recovery  from  the  small-pox.  They  are 


280  OPHTHALMOL  OGY. 

usually  ulcerations  and  parenchymatous  inflammations,  which 
lead  to  the  formation  of  scars,  or  even  to  total  destruction  of 
the  eyeball.  Many  an  eye  which  has  been  lost  in  this  manner 
might  have  been  saved,  had  the  eye-  affection  been  treated  in 
its  earlier  stages,  and  as  the  treatment  is  in  most  cases  simply 
local,  and  in  no  way  interfering  with  the  treatment  of  the 
small-pox,  there  is  no  good  excuse  for  neglecting  it,  even  dur- 
ing the  active  period  of  the  general  disease. 

Typhus  abdominalis  may  give  rise  to  corneal  abscesses  or 
ulcerations,  paresis  of  the  external  muscles  of  the  eyeball  or 
of  the  accommodative  apparatus,  or  to  orbital  cellulitis. 

Amblyopia  and  amaurosis  are  sometimes  seen  after  typhus, 
as  they  are  after  other  prostrating  diseases,  and  are  due  to  an 
anaemic  condition  of  the  optic  nerves.  In  nearly  all  of  these 
cases  sight  returns  with  the  improvement  of  the  condition  of 
the  general  system.  Sometimes  atrophy  of  the  optic  nerve  is 
observed. 

Febris  recurrens  is  said  to  cause  by  preference  affections  of 
the  uveal  tract. 

Diphtheritis  of  the  throat  appears  very  seldom  to  cause  diph- 
thentic  conjunctivitis,  but  in  some  rare  cases  the  disease  reaches 
the  conjunctiva  through  the  lachrymal  passages.  A  much  more 
frequent  affection  following  diphtheritis  of  the  throat  is  pare- 
sis of  the  accommodation,  already  referred  to  in  Chapter  XX. 
The  physician  should  at  once  suspect  it,  when  some  weeks 
after  recovery  from  the  diphtheritic  attack  in  the  throat,  vision 
for  near  objects  becomes  weakened  or  imperfect. 

Malarial  fever^  as  has  been  stated,  is  thought  by  many  phy- 
sicians in  the  Mississippi  Valley  to  cause  all  sorts  of  eye-affec- 
tions. There  is  no  question  that  chronic  conjunctivitis  and 
trachoma,  are  very  frequent  in  the  fever  districts,  yet,  I  have 
not  seen  that  quinine  has  had  any  beneficial  influence  in  pro- 
moting their  cure.  Malarial  keratitis  has  been  described  {Kipp) 
as  a  special  form  of  keratitis.  I  have  sometimes  seen  small, 
point-like  infiltrations  of  the  cornea,  which  have  appeared  in 
connection  with  malarial  fever.  Malarial  optic  neuritis  and 
oedema  of  the  optic  papilla  have  been  described  by  Macnam- 
ara.  Paralysis  of  one  or  more  of  the  external  muscles  of  the 
eyeball  may  also  be  due  to  malarial  poisoning. 


EYE-AFFECTIONS  IN  OTHER  DISEASES.  281 

Cerebrospinal  meningitis  may  cause  partial  or  total  atrophy 
of  one  or  both  optic  nerves  by  constriction  of  the  nerves  at 
the  base  of  the  brain.  In  some  cases  it  produces  purulent 
panophthalmitis. 

The  recent  epidemic  of  influenza  (^grippe")  has  shown  this 
disease  capable  of  bringing  about  numerous  forms  of  eye  diseas- 
es. Abscesses  of  the  lids,  very  severe  acute  conjunctivitis, 
phlegmome  of  the  orbit,  paralysis  of  ocular  muscles,  optic 
neuritis,  atrophy  of  the  optic  nerve,  iritis  and  severe  cases  of 
purulent  panophthalmitis,  have  all  come  under  my  own  ob- 
servation as  sequelae  of  influenza. 

Tuberculosis  may  affect  the  conjunctiva,  and  is  found  in  the 
uveal  tract.  It  may  be  the  primary  form  of  infection,  or  the 
ocular  tuberculosis  is  due  to  the  dissemination  from  some 
other  center  of  infection. 

Pycemia  and  septiccemia  cause  eye-symptoms,  which  may  be 
due  to  the  thrombosis  of  the  cavernous  sinus,  or  of  one  of  the 
ophthalmic  veins.  In  other  cases,  especially  in  puerperal  sep- 
ticaemia, purulent  choroiditis  [choroiditis  metastatica),  due  to 
microbic  embolism,  has  been  observed.  I  have  seen  it  also 
follow  a  purulent  arthritis,  A  septic  retinitis  has  also  been 
obsen/ed  and  described. 

Acquired  syphilis  shows  itself  in  the  eyes  in  a  great  many 
ways,  and  in  all  periods  of  the  disease.  Primary  chancres  have 
been  met  with  on  the  skin  of  the  lids  and  on  the  conjunctiva. 
The  part  of  the  eye  most  frequently  attacked  by  syphilis  is 
the  uveal  tract.  The  commonest  form  of  syphilitic  eye-disease 
is  iritis.  It  is  usually  a  simple  plastic  iritis,  which  appears  at 
the  same  time  with  the  skin  symptoms,  or  at  a  later  period 
when  other  syphilitic  symptoms  are  no  longer  recognizable. 
In  some  cases  the  iritis  is  of  .a  recurring  type.  Such  a  plastic 
syphilitic  iritis  may  begin  rather  quietly  and  with  but  little 
pain,  and  may  thus  differ  somewhat  from  certain  other  forms 
of  iritis;  yet,  as  a  rule,  there  is  no  symptom  which  absolutely 
proves  an  iritis  to  be  of  syphilitic  origin,  unless  it  be  the  form- 
ation of  a  gumma.  Gumma  of  the  iris  is  easily  recognized,  as 
has  been  described  in  Chapter  X.  The  gumma  may  remain 
small,  or  it  may  gradually  increase  in  size  so  as  to  nearly  fill 
the  anterior  chamber. 


282  OPHTHALMOLOGY. 

Syphilitic  choroiditis  may  appear  as  disseminate  choroiditis 
or  as  a  central  chorio-retinitis,  or  it  may  be  an  exudative  cho- 
roiditis. Gummata  have  also  been  observed  in  the  choroid. 
Syphilitic  choroiditis  is  found  in  patients  of  a  more  advanced 
age,  and  occurs  mostly  at  the  same  time  with  or  soon  after 
the  so-called  secondary  symptoms,  or  at  a  very  late  period. 

Syphilitic  retinitis,  usually  conjoined  with  choroiditis,  and 
syphilitic  neuritis,  are  sometimes  met  with;  also  cyclitis,  gum- 
mata of  the  ciliary  body  and  of  the  sclerotic.  Atrophy  of  the 
optic  nerve  and  paralytic  symptoms  in  the  external  muscles  of 
the  eyeball  are  often  due  to  syphilis.  Sometimes  it  causes 
diseases  of  the  lachrymal  apparatus  and  chronic  hyperaemia  of 
the  conjunctiva  bulbi. 

Hereditary  syphilis  is  often  the  cause  of  parenchymatous  ker- 
atitis, and  sometimes  of  iritis  and  choroiditis.  Such  a  keratitis 
is  also  occasionally  caused  by  acquired  syphilis,  and  I  have 
seen  it  follow  slight  injuries  to  the  cornea  in  syphilitic  subjects. 

§164.  Intoxications. — Lead-poisoning  is  apt  to  cause  optic 
neuritis,  transient  amaurosis  or  even  atrophy  of  the  optic 
nerve.  The  eye-affection  generally  precedes  the  general 
symptoms. 

Progressive  atrophy  and  central  scotoma  due  to  alcohol  and 
tobacco  intoxication,  have  been  detailed  in  Chapter  XIV. 

Toxic  effects  from  eating  foul  sausage,  meat-pastry  or  fish 
(pike),  have  in  rare  cases  produced  a  paresis  of  the  accommoda- 
tion, exactly  like  that  observed  after  diphtheritis.  Sometimes 
it  has  been  conjoined  with  amblyopia. 

Intoxication  with  belladonna,  hyoscyamus,  datura,  duboisia 
and  gelsemium,  causes  dilatation  of  the  pupil  and  paralysis  of 
the  accommodation. 

Morphia  and  opium  intoxication,  in  the  acute  forms,  causes 
miosis  of  the  pupil. 

Quinine  intoxication  has  especially  of  late  been  found  to 
cause  amblyopia  and  amaurosis.  The  latter  may  become  per- 
manent, or  some  small  area  of  the  field  or  even  central  vision 
may  be  re-established.  The  ophthalmoscope  shows  anaemia 
of  the  optic  nerve  and  retina.  The  affection  usually  leaves  an 
impairment  of  the  color-sense  and  the  Hght  sense  behind  even 
if  vision  is  regained. 


EYE-AFFECTIONS  IN  OTHER  DISEASES.  283 

§165.  Diabetes. — Diabetes  mellitus  is  sometimes  the  cause 
of  the  formation  of  cataract.  While  some  operators  are  afraid 
to  extract  such  cataracts,  and  prefer  to  use  the  suction  method, 
others  do  not  acknowledge  any  special  danger  from  operations 
for  diabetic  cataract.  I  have  never  seen  any  disagreeable  acci- 
dent following  extraction  in  such  cases. 

The  optic  nerve  and  retina  are  sometimes  found  to  be  in- 
flamed in  diabetes  mellitus,  and  the  ophthalmoscopic  picture 
is  similar  to  that  of  albuminuric  neuro-retinitis.  Furthermore, 
amblyopia  and  atrophy  of  the  optic  nerve  and  paralysis  of  the 
external  muscles  of  the  eyeball  have  been  found,  caused  ap- 
parently by  diabetes. 

Rheumatism  may  give  rise  to  iritis,  and  it  is  especially  the 
chronic  relapsing  form  of  iritis  which  is  usually  ascribed  to  it. 
Some  forms  of  paralysis  of  the  external  muscles  of  the  eye 
and  of  episcleritis,  for  which  no  other  cause  can  be  found,  are 
conventionally  termed  rheumatic. 

Iritis  is  also  often  due  to  a  gouty  diathesis,  and  sometimes 
cyclitis  is  dependent  on  the  same  general  disease. 

Scrophulosis. — Scrophtdosis,  strumous  habit,  is  the  most  fre- 
quent cause  of  phlyctaenular  affections  of  the  eye  and  some- 
times of  parenchymatous  keratitis,  chronic  catarrhal  conjunc- 
tivitis, blepharitis  and  affections  of  the  lachrymal  apparatus. 


CHAPTER    XXV.— ON    THE    DETECTION    OF    ONE- 

SIDED      SIMULATED      BLINDNESS      AND 

CONGENITAL  COLOR-BLINDNESS. 

§i66.  The  oldest  and  simplest  method  for  the  detection  of 
simulated  one-sided  blindness  consists  in  placing  a  prism  before 
the  eye  which  is  pronounced  to  be  healthy,  while  the  individ- 
ual is  looking  at  a  distant  object,  and  thus  to  evoke  double 
vision.  It  is  best  to  hold  the  prism  before  that  eye  with  its 
base  upwards  or  downwards.  If  the  individual  under  exami- 
tion  acknowledges  his  diplopia,  the  eye  pronounced  blind 
must  necessarily  see,  and  his  binocular  vision  is  demonstrated. 

In  many  cases,  however,  the  malingerer  is  acquainted  with 
this  method,  and  it  must  then  be  modified.  He  is  directed 
again  to  look  at  a  distant  object;  then  the  examiner  covers  the 
so-called  blind  eye,  and  holds  a  prism  before  the  so-called 
good  eye  in  such  a  manner  that  the  prism  covers  only  about 
half  the  pupillary  space,  thus  producing  a  monocular  diplopia. 
If  the  malingerer  does  not  acknowledge  this  diplopia,  he  is  to 
be  suspected.  If  he  acknowledges  it,  we  proceed  to  uncover 
the  so-called  blind  eye,  and  shift  the  prism  so  that  it  covers 
the  whole  pupil,  thus  changing  the  monocular  into  a  binocular 
diplopia.  He  must,  of  course,  not  be  allowed  to  suspect  the 
trick,  and  if  he  continues  to  *see  double,  the  so-called  blind 
eye  must  see.  If  the  prism  be  used  in  the  same  manner,  and 
no  eye  is  covered,  three  images  must  appear,  and  this  method 
may  be  used  in  certain  cases. 

Another  method  is  to  let  the  malingerer  read,  and  to  ex- 
clude his  so-called  good  eye  from  sight  by  some  means  while 
he  is  reading.  This  may  best  be  done  by  holding  a  very 
strong  convex  glass  before  it,  as  but  few  malingerers  will  be 
stupid  enough  to  go  on  reading,  when  a  dark  or  ground  glass 
is  held  before  their  so-called  good  eye. 

If,  further,  the  malingerer  goes  on  reading  undisturbed  and 

—284— 


SIMULATED  ONE-SIDED,  AND  COLOR-BLINDNESS.         285 

without  shifting  the  book  or  his  head,  when  a  pencil  or  some 
such  object  is  held  between  his  eyes  and  the  book,  he  must  see 
with  both  eyes. 

Another  excellent  test  {Snellen)  makes  use  of  red  and  green 
letters  which  the  patient  is  made  to  read  through  red  and 
green  glasses.  If  the  green  glass  is  held  before  the  good  eye  he 
can  only  see  the  green  letters,  or  if  the  red  glass  is  held  be- 
fore it  he  can  only  see  the  red  letters.  Of  course  if,  under 
the  circumstances,  he  reads  all  the  letters,  he  must  see  with 
both  eyes. 

The  so-called  good  eye  may  also  be  excluded  from  vision 
by  the  instillation  of  a  mydriatic.  However,  but  few  maling- 
erers will  allow  anything  to  be  put  into  their  so-called  good 
eye. 

§167.  Congenital  color-blindness. — Color-blindness  has  of 
late  become  an  important  subject  in  certain  branches  of  mod- 
ern civilization.  The  fact  that  a  man  is  color-blind,  evidently 
unfits  him  for  any  service  in  which  the  prompt  fulfillment  of 
important  duties  depends  on  his  recognizing  colored  signals. 

It  has,  therefore,  become  a  law  in  most  civilized  countries 
that  men  applying  for  positions  in  the  railroad  service,  or  in 
the  marine,  must  first  undergo  an  examination  with  regard  to 
their  color-perception. 

Color-blindness  may  be  total  or  only  partial.  In  total  color- 
blindness the  patient  perceives  only  black  and  white,  and  all 
other  colors  are  to  him  either  white  or  black  or  some  interme- 
diate shade  of  gray.  In  partial  color-blindness  the  patients 
generally  see  two  complementary  colors  besides  white  and 
black.  In  the  so-called  red-green  blindness  yellow  and  blue 
are  perceived;  in  the  so-called  blue-yellow  blindness  red  and 
green  are  recognized.  These  two  forms  are  the  typical  ones 
of  partial  color-blindness,  yet  slight  variations  are  often  ob- 
served. The  visual  acuteness  of  eyes  which  are  color-blind  is 
generally  perfectly  normal. 

Various  methods  have  been  devised  in  order  to  detect  par- 
tial congenital  color-blindness.  The  simplest  in  common  use 
is  that  of  Holmgren.  The  patient  is  given  a  skein  of  colored 
worsted,  and  directed  to  select  from    a   bundle  containing   all 


286  OPHTHALMOL  OG  Y. 

sorts  of  colored  worsted  those  skeins  which  appear  to  him  of 
the  same  color  as  the  given  one  (usually  at  first  a  pale  green  or 
a  pale  pink).  If  there  is  any  hesitation  in  matching  the  color,  or 
if  he  selects  different  colors  to  match  the  given  one,  his  color- 
perception  cannot  be  normal. 

If,  for  instance,  he  matches  a  light  green  skein  with  red, 
brown  or  gray,  he  is  surely  color-blind.  If  he  is  red-green 
blind,  he  will  mix  the  colors  up  on  the  principle  that  to  him 
blue  and  yellow  only  are  distinct  colors,  and  all  other  colors 
appear  to  him  as  shades  of  yellow  {Mauthner).  If  he  is, 
however,  blue-yellow  blind,  he  will  see  only  red  and  green  as 
distinct  colors,  and  every  other  color  will  appear  to  him  as  a 
shade  of  red. 

Red -green  blindness  is  by  far  the  commonest  form  of  par- 
tial color-blindness. 

The  affection  is  but  very  rarely  monocular,  and  nothing  defi- 
nite is  known  with  regard  to  its  etiology,  although  it  is  most 
likely  due  to  a  lack  of  development  of  the  center  for  color- 
perception. 

Acquired  color-blindness,  associated  with  progressive  atrophy 
of  the  optic  nerve,  has  been  detailed  in  Chapter  XIV. 


CHAPTER    XXVL— ASEPSIS    AND    ANTISEPSIS    IN 
OPHTHALMIC     SURGERY.      DESCRIPTION 
OF    THE    MOST    IMPORTANT    OPER- 
ATIONS   ON    THE    EYE    AND 
THE     EYELIDS. 

§i68.  Whether  a  surgeon  be  a  believer  in  the  theory  of  the 
microbian  origin  of  disease  or  not  he  cannot,  at  this  day,  afford 
to  disregard  the  methods  of  asepsis  and  antisepsis,  by  which 
surgery  has  made  such  undoubtedly  great  strides  towards  per- 
fection. In  ophthalmic  surgery  in  this  regard  the  same  rules 
hold  good  as  do  elsewhere.  We  must  strive  to  be  aseptic,  to 
operate  with  aseptic  instruments,  and  to  render  as  far  as  possi- 
ble aseptic,  and  keep  it  so,  the  field  of  our  operative  interfer- 
ence. Where  asepsis  cannot  be  produced,  antisepsis  must 
take  its  place.  How  the  surgeon  is  to  render  himself  and  the 
surroundings  of  the  patient  sufficiently  aseptic  (the  ideal  can 
never  be  reached)  we  can  not  detail  here.  The  instruments  are 
best  made  aseptic  by  being  placed  in  boiling  water  or  by  ster- 
ilizing them  by  means  of  steam.  When  this  cannot  be  done  they 
should  be  placed  into  a  two  per  cent,  solution  of  carbolic  acid 
or  creoline.  As  both  these  solutions  are  apt  to  affect  the  ^^^^ 
of  cutting  instruments  disagreeably,  the  latter  are  best  disin- 
fected by  means  of  absolute  alcohol.  The  neighborhood  of 
the  eye,  particularly  the  eyebrows  and  eyelashes  and  their 
roots  are  best  disinfected  by  first  scrubbing  and  washing  them 
with  soap  and  then  with  a  solution  of  bichloride  of  mercury 
of  one  part  in  four  thousand.  It  is  well  in  order  to  allow  the 
bichloride  of  mercury  solution  to  remain  in  better  contact 
with  the  parts  to  be  disinfected,  to  cover  them  for  some  time 
just  before  the  operation  with  a  layer  of  cotton  saturated  with  it. 
The  conjunctival  sack  must  be  repeatedly  flushed  with  the  same 
solution  just  before  operating.    Other  solutions  or  powders  are 

—287— 


288  OPHTHALMOLOG  V. 

used  by  others  to  reach  the  same  end  (boracic  acid,  carboli 
acid,  iodoform,  aristol,  etc.).  All  drugs  in  solution  dropped  into 
the  eye  in  connection  with  an  operation,  as  cocaine,  eserine  and 
atropine,  must  be  sterilized  if  possible,  by  heating.  Cocaine  and 
atropine  should  be  dissolved  in  a  four  per  cent,  solution  of  bo- 
racic acid,  instead  of  distilled  water  alone.  Scrupulous  asep- 
sis and  antisepsis  are  to  be  carried  out  by  these  means  or 
others.  When  in  spite  of  all  precautions  an  infection  of  the 
operative  wound  takes  place,  the  last  resort  is  cauterization  by 
means  of  the  actual  or  galvano-cautery.  If  there  is  any  stop- 
page in  the  lachrymal  drainage  apparatus,  or  any  infectious 
disease  of  the  conjunctiva  present,  it  must  be  rendered  innoc- 
uous before  an  operation  on  the  eyeball  is  performed.  The 
method  of  bandaging,  which  I  consider  the  ideal  one,  has  been 
detailed  in  Chapter  VI. 

§169.  General  anaesthesia  is  but  seldom  required  in  opera- 
tions on  the  eyeball,  except  in  children,  since  Koller's  discov- 
ery has  given  us  the  local  anaesthetic,  cocaine.  It  is  best  to 
use  this  in  a  two  to  four  per  cent,  solution  and  to  instill  it 
into  the  conjunctival  sack  several  times  at  short  intervals 
(from  three  to  five  minutes)  before  an  operation  on  the 
eyeball  is  performed.  It  may  also  with  advantage  be  in- 
jected under  the  skin  of  the  lids  and  into  the  deeper  tissues  of 
the  orbit  in  certain  operations,  but  the  pain  it  causes  and  the 
possibility  of  poisonous  effects  are  serious  objections  against 
this  manner  of  causing  local  anaesthesia.  Tropa-cocaine  is  now 
recommended  as  non-poisonous  and  less  irritating,  in  the  place 
of  cocaine,  particularly  for  injections. 

The  ophthalmic  surgeon  should  be  ambidexter,  that  is,  he 
should  have  trained  his  left  hand  to  be  as  useful  and  free  in 
action,  or  nearly  so,  as  his  right  hand. 

§170.  Tenotomy. — The  tenotomy  of  one  or  more  of  the  ex- 
ternal muscles  of  the  eyeball  is  performed  for  the  correction  of 
strabismus  or  insufficiency.  The  operation  is  most  frequently 
done  on  the  internal  rectus,  more  rarely  on  the  external  rectus 
and  others. 

When  possible,  it  is  best   to  perform  this  operation  without 


OPERATIONS.  289 

putting  the  patient  under  the  influence  of  a  general  anaesthetic 
because  the  effect  of  the  tenotomy  can  then  be  promptly  es- 
timated, and,  if  necessary,  be  improved  upon.  By  the  help 
of  cocaine  this  can  be  easily  done,  even  in  comparatively  small 
children. 

After  the  eyelids  have  been  separated  and  are  held  apart  by 
means  of  a  wire-speculum,  or  by  the  fingers  of  an  assistant, 
the  patient  is  ordered  to  roll  the  eyeball  in  the  direction  oppo- 
site to  the  muscle  to  be  cut.  The  conjunctiva  and  episcleral 
tissues  are  then  firmly  grasped  with  strong  toothed  forceps 
below  the  insertion  of  the  muscle  and  somewhat  nearer  the 
corneo-scleral  margin.  The  fold  of  tissue  thus  grasped  is  then 
cut  by  means  of  strabismus  scissors.  If  the  first  clip  has  not 
severed  Tenon's  capsule,  this  must  be  done  by  a  second  cut. 
When  this  is  accomplished,  but  not  before,  the  strabismus 
hook  is  slipped  under  the  tendon  of  the  muscle  through  this 
external  incision.  The  handle  of  the  hook  is  then  raised  so 
as  to  put  the  muscle  upon  the  stretch,  the  strabismus  scissors 
are  introduced  and  the  tendon  is  cut  close  to  the  sclerotic.  By 
then  bringing  a  second  strabismus  hook  behind  the  first  one, 
entering  it  with  its  point  downwards  and  sweeping  the  sclerot- 
ic with  it  while  turning  the  point  upwards,  or  vice  versa,  any 
stray  tendinous  fibres  are  detected,  and  are  to  be  severed. 
Only  when  the  strabismus  hook  can  be  moved  under  the  con- 
junctiva close  up  to  the  corneo-scleral  margm,  without  encoun- 
tering any  obstacle,  we  may  be  sure  that  the  muscle  is  per- 
fectly divided. 

When  this  is  done,  the  effect  of  the  operation  should  be 
tested.  If  the  motility  of  the  eyeball  in  the  direction  of  the 
muscle  operated  upon  is  greatly  reduced,  the  desired  effect  is 
probably  attained.  If  the  internal  rectus  has  been  cut,  the 
patient  ought  to  be  able  to  move  the  inner  margin  of  the  cor- 
nea as  far  inward  as  the  lachrymal  caruncle,  and  if  he  can  not 
do  this,  the  effect  of  the  tenotomy  may  be  reduced  by  draw- 
ing the  eyeball  by  a  suture  to  the  inner  angle  of  the  palpebral 
fissure  (Knapp).  If  the  patient  can  move  his  eye  farther  to- 
ward the  nose,  the  tendon  is  not  perfectly  divided,  and  the 
hook  and  scissors  must  be  re-introduced. 

If  tenotomy  has  been  performed  on  the  external  rectus,  the 


290  OPHTHALMOLOG  \. 

patient  should  still  be  able  to  move  the  outer  margin  of  the 
cornea  as  far  as  the  outer  angle  of  the  palpebral  fissure;  and 
if  he  cannot  do  so,  the  effect  of  the  operation  may  be  reduced 
by  drawing  the  eyeball  to  the  outer  angle  of  the  palpebral 
fissure  by  means  of  a  suture.  To  increase  the  effect  of  a  ten- 
otomy a  suture  must  be  placed  in  the  opposite  angle  of  the 
palpebral  fissure. 

Tenotomy  has  generally  to  be  performed  on  both  eyes  in 
order  to  gain  a  perfect  result.  This  must,  however,  never  be 
done  at  one  sitting,  when  the  tenotomy  is  made  to  cure  con- 
vergent strabismus,  since  an  over-correction  may  result  in  a  di- 
vergent strabismus  in  place  of  the  convergent  one,  for  which 
the  operation  has  been  performed. 

Partial  tenotomies  which  are  said  to  enable  the  surgeon  bet- 
ter to  grade  the  effect  of  the  operation,  have  been  introduced 
as  substitutes  for  total  tenotomy' of  the  antagonist  of  an  insuf- 
ficient muscle  {Stevens).  Instead  of  severing  the  tendon 
of  such  a  muscle  a  piece  is  cut  out  of  it  by  specially  de- 
vised small  instruments  in  the  hope  of  weakening  the  an- 
tagonist just  to  the  degree  required  to  establish  the  equilibrium 
between  the  two  muscles.  The  results,  from  what  I  have  seen, 
seem  very  doubtful. 

§171.  Advancement  oi  an  ocular  muscle  may  be  performed 
alone  or  combined  with  tenotomy  of  the  antagonist.  While 
tenotomy  attempts  to  render  a  too  strong  muscle  weaker  by 
causing  its  insertion  to  be  moved  backwards  on  the  eyeball, 
advancement  renders  the  weak  muscle  more  effective  in  its  ac- 
tion by  shortening  it,  or  by  bringing  about  an  insertion  closer 
to  the  cornea,  or  by  both  measures  together. 

By  some  operators  this  latter  method  of  correcting  strabis- 
mus is  always  considered  to  be  the  preferable  one.  Its  appli- 
cation is  commonest,  however,  in  divergent  strabismus,  as  a 
simple  tenotomy  of  the  external  rectus  or  recti  in  this  affection 
is  but  seldom  successful.  It  is,  therefore,  necessary  in  these 
cases  to  advance  the  insertion  of  the  internal  rectus  to  a  posi- 
tion nearer  the  corneo-scleral  margin,  and  thus  in  effect  to 
shorten  the  muscle.  The  operation  for  the  advancement  of 
the  internal  rectus  must  nearly  always  be  combined  with  the 


OPERATIONS,  291 

division  of  the  external  recti,  and  in  some  cases  it  may  be 
necessary  to  perform  the  operation  for  advancement  on  both 
internal  recti. 

The  conjunctiva  is  first  incised  over  the  insertion  of  the  in- 
ternal rectus  in  a  vertical  direction,  and  the  muscle  is  grasped 
with  the  forceps,  or  a  thread  is  drawn  through  it,  so  as  to  pre- 
vent it  from  slipping  backwards  and  out  of  reach  when  the 
tendon  is  cut.  This  cutting  of  the  tendon  is  done  close  to  the 
sclerotic,  and  the  muscle  may,  if  necessary,  be  shortened  to 
the  required  degree  by  cutting  off  a  piece.  When  this  is 
done,  the  portion  of  the  conjunctiva  which  lies  between  the  in- 
cision and  the  corneal  margin  is  indermined  with  fine  scis- 
sors, and  the  internal  rectus  is  drawn  under  it,  and  fastened  in 
this  position  by  means  of  two  or  three  sutures.  (See  Fig.  124). 


Fig.  124. — Advancement  of  the  rectus  exteraus. 

The  required  effect  is  only  reached  when  immediately  after 
the  operation,  the  eyes  show  a  slight  degree  of  convergence. 
This  apparent  over-correction  disappears  during  the  process  of 
healing. 

A  more  modern  procedure  introduced  by  De  Weaker  is  the 
advancement  of  Tenon's  capsule  by  means  of  a  suture,  which 
causes  a  fold  in  the  muscle.  When  this  fold  has  become  ad- 
herent to  the  underlying  part  of  the  muscle,  the  muscle  is 
practically  shortened  and  accordingly  stronger. 

§172.    Enucleation  of  the  eyeball. — The  operation  of  remov- 


292  OPHTHALMOLOGY, 

ing  an  eyeball  by  enucleation  is  in  most  cases  best  performed 
while  the  patient  is  under  the  influence  of  a  general  anaesthetic. 
When  necessary  it  can,  however,  be  done  under  local  cocaine 
anaesthesia. 

The  eyelids  are  held  apart  by  a  wire  speculum  or  by  the  fin- 
gers of  an  assistant,  and  the  conjunctiva  at  the  periphery  of  the 
cornea  and  near  the  insertion  of  one  of  the  recti  muscles,  pref- 
erably the  inferior  one,  is  grasped  with  the  toothed  forceps 
and  freely  incised.  A  strabismus  hook  is  then  inserted  under 
the  muscle,  and  all  the  tissue  which  can  be  lifted  up  by  the  hook 
is  divided  with  the  scissors  close  to  the  eyeball,  always  cut- 
ting the  conjunctiva  first  at  the  corneo-scleral  margin.  When 
all  the  tissue  which  has  been  lifted  by  the  first  hook  is  severed, 
a  second  hook  is  inserted  behind  the  first  one,  and  the  tissues 
lifted  by  this  one  are  cut  in  turn,  and  so  on  around  the  periph- 
ery of  the  cornea.  When  the  tendons  of  the  .  inferior,  exter- 
nal and  superior  rectus  have  thus  been  detached,  it  is  best  to 
divide  the  internal  rectus  somewhat  further  back  from  its  in- 
sertion so  that  the  stump  adhering  to  the  sclerotic  can  be  used 
in  order  to  rotate  the  eyeball  outwards  during  the  final  step  of 
the  operation,  which  is  the  cutting  of  the  optic  nerve.  To  ac- 
complish this  the  eyeball  is  turned  strongly  outwards  (some 
operators  prefer  to  turn  it  inwards,  strange  to  say),  and  a  large 
strongly  curved  pair  of  scissors  is  introduced,  with  blades 
closed,  at  the  nasal  side  between  the  loosened  orbital  tissue 
and  the  eyeball,  and  is  pushed  backwards  until  it  has  reached 
the  posterior  surface  of  the  eyeball.  By  moving  the  point  of 
the  scissors  up  and  down,  the  resistence  felt  will  now  enable 
the  operator  to  make  sure  of  the  position  of  the  optic  nerve. 
When  this  is  ascertained,  the  scissors  are  slightly  withdrawn, 
opened  and  advanced  again,  so  as  to  catch  the  optic  nerve  be- 
tween the  blades.  The  optic  nerve  and  the  ciliary  nerves 
around  it  are  then  divided  by  one  clip  of  the  scissors,  and  the 
eyeball  is  lifted  out  of  the  orbit  with  the  scissors.  The  oblique 
muscles  and  any  further  adhesions  are  now  cut  as  quickly  as 
possible,  since  a  comparatively  profuse  haemorrhage  takes 
place  as  soon  as  the  optic  nerve  is  severed. 

§173.    Paracentesis  of  the  cornea. — Paracentesis  (puncture)  of 


OPERATIONS.  293 

the  cornea  and  emptying  of  the  anterior  chamber  is  performed 
for  the  relief  of  an  increased  intraocular  tension,  or  for  the 
removal  of  pus  or  other  pathological  contents  from  the  ante- 
rior chamber. 

This  little  operation  is  usually  performed  by  means  of  a 
needle,  a  stop-needle,  or  a  small  lance-shaped  knife.  In  punc- 
turing the  cornea,  great  care  must  be  taken  not  to  wound  the 
iris  or  the  crystalline  lens,  as  the  former  may  lead  to  haemor- 
rhage or  iritis  and  the  latter  will  cause  a  cataract  to  develop. 

§174.  Abscision  of  a  total  corneal  staphyloma. — Corneal 
staphylomata  are,  as  a  rule,  cut  off  by  detaching  the  lower  or 
upper  half  of  the  protrusion  with  a  Beer's  knife,  and  the  remain- 
ing half  with  scissors. 

If  the  crystalline  lens,  which  is  usually  cataractous,  is  still  in 
in  situ,  it  should  be  removed  after  opening  the  anterior  lens 
capsule. 


Fig.  125. — Removal  of  a  total  staphyloma  of  the  cornea.    The  sutures  are  in  situ 
according  to  the  method  of  Knapp. 

The  wound  resulting  from  this  operation  may  be  left  to  heal 
without  further  interference,  or  it  may  be  closed  by  sutures. 
The  sutures  must  be  inserted,  ready  to  be  tied,  before  the 
staphyloma  is  removed.  This  is  generally  best  done  by  Knapp* s 
method.  A  needle  armed  with  a  long  thread,  is  entered  under 
the  conjunctiva  and  episclera  above  the  upper  corneo-scleral 
margin,  and  a  little  to  one  side  of  the  vertical  meridian,  and 
is  brought  out  somewhat  above  the  horizontal  meridian  on  the 


294  OPHTHALMOLOGY. 

same  side;  it  is  then  entered  again  a  little  below  this  meridian 
and  brought  out  at  a  point  below  the  lower  corneo-scleral 
margin  corresponding  to  the  first  point  of  entrance.  (See  Fig. 
125).  The  same  procedure  is  then  repeated  on  the  other  side 
of  the  vertical  meridian.  After  the  removal  of  the  staphyloma 
the  threads  are  tied  and  the  wound  is  closed.  By  this  means 
an  excellent  stump  for  the  wearing  of  an  artificial  eye  may  be 
obtained. 

§175.  Evisceration  has  been  of  late  introduced  as  a  substitute 
for  enucleation  for  various  reasons  (-^.6^r^^/>),chief  among  which 
is  the  erroneous  idea  that  removing  a  panophthalmitic  eye  may 
cause  meningitis.  The  sclerotic  being  incised  concentrically  with 
the  periphery  of  the  cornea  and  near  it  with  a  knife,  the  circular 
section  is  completed  by  means  of  scissors.  The  cornea  and  a 
ring  of  sclerotic  tissue  attached  to  it  are  thus  cut  off.  The 
contents  of  the  eyeball  are  then  rernoved  and  the  inner  sur- 
face of  the  scleral  shell  is  scraped  clean  with  a  sharp  spoon. 
The  conjunctival  and  scleral  wound  lips  may  now  be  closed 
by  suiures.  In  order  to  improve  upon  the  stump  resulting 
from  this  operation,  Mules  has  devised  an  artificial  vitreous 
body,  a  ball  of  glass  or  some  other  light  and  uncorrodable 
material,  which  is  inserted  into  the  scleral  shell  before  closing 
the  wound. 

The  healing  after  this  operation  is  very  painful  and  protract- 
ed.    Its  value  is  doubtful. 


Fig.  126. — Scleral  incision  leaving  a  bridge  upwards.      Von  VVecker's   sclerotomy. 

§176.  Sclerotomy. — The  operation  of  sclerotomy  is  per- 
formed to  relieve  an  increased  intraocular  tension,  and  has  of 
late  been  especially  recommended  as  a  means  of  curing  cer- 
tain forms  of  glaucoma.  The  operation  is  generally  perform- 
ed with  a  Graefe^s  cataract  knife.  This  knife  is  entered  in  the 
coineo-scleral  margin   just  in  front  of  the  insertion  of  the  iris, 


OPERATIONS,  295 

and  is  brought  out  on  the  opposite  side  of  the  cornea,  in  the 
corneo-scleral  tissue.  The  section  may  now  be  finished,  and 
thus  a  corneo-scleral  flap  be  formed  (See  Fig.  126),  or,  what  is 
better,  because  it  is  less  likely  to  be  followed  by  prolapse  and 
subsequent  incarceration  of  the  iris,  a  narrow  bridge  of  cor- 
neo-scleral tissue  is  left  uncut  {De  Wecker).  The  knife  is  then 
slowly  withdrawn  and  eserine  instilled. 

§177.  Iridectomy .—T\it.  operation  of  iridectomy,  which  con- 
sists in  the  removal  of  a  sector  of  iris-tissue,  is  one  of  the  op- 
erations most  frequently  performed  upon  the  eyeball.  It  is 
the  ordinary  operation  for  an  artificial  pupil  to  restore  sight  to 
an  otherwise  useless  eye,  and  for  the  relief  of  increased  intra- 
ocular tension  in  cases  of  primary  or  secondary  glaucoma;  it 
may  also  make  a  part  of  an  operation  for  the  extraction  of  cat- 
aract, or  the  removal  of  a  foreign  body  lodged  in  the  eye. 

The  cornea  is  incised  by  means  of  a  lance-shape  knife  or  a 
Graefe's  cataract  knife  in  the  corneo-scleral  tissue,  or  nearer 
its  center  when  a  very  small  pupil  is  desired.  When  the  knife 
is  withdrawn,  the  irib  may  at  once  prolapse,  in  which  case  it  is 
easily  grasped  by  a  pair  of  iris  forceps,  is  gently  pulled  out 
and  cut  off  as  close  to  its  ciliary  insertion  as  possible.  If  the 
iris  does  not  prolapse,  the  forceps  must  be  introduced  through 
the  corneal  incision,  in  order  to  grasp  and  draw  it  out.  (See 
Fig.  127). 


Fig.  127. — Scleral  incision  for  iridectomy  and  appearance  of  the  pupil  after  comple- 
tion of  the  iridectomy. 

Great  care  must  be  taken  during  this  operation  not  to  wound 
the  crystalline  lens,  as  this  would  subsequently  cause  the  form- 


296  OPHTHALMOLOGY. 

ation  of  cataract;  also  that  no  iris-tissue  is  allow^ed  to  remain 
lying  between  the  lips  of  the  corneal  incision,  since  this  might 
give  rise  to  the  formation  of  an  ectatic  scar  and  later  infection 
through  it. 

In  eyes  in  which  vision  has  become  abolished  inconsequence 
of  a  plastic  iritis  with  occlusion  of  the  pupil,  it  is  sometimes 
very  desirable  but  not  at  all  easy  to  re-establish  some  kind  of 
a  pupillary  opening.  It  is  generally  necessary  to  use  iris  for- 
ceps with  a  different  arrangement  of  the  teeth  or  a  blunt  hook 
(TyrelV s)  in  order  to  get  hold  of  the  iris.  The  variations  in 
this  little  operation  are  almost  as  numerous  as  the  cases  on 
which  it  has  to  be  performed. 

§178.  Iridotomy. — The  operation  called  iridotomy  or  irito- 
my  [De  Wecker)  is  now  often  executed  with  the  iridotomy 
scissors  introduced  by  De  Wecker.  Its  usefulness  is  most 
marked  in  those  cases  in  which  after  a  cataract  extraction  a 
secondary  membranous  cataract  has  been  formed,  or  where  in 
consequence  of  irido-cyclitis  (especially  after  an  injury  with 
loss  of  the  crystalline  lens)  the  iris  and  cyclitic  membrane  to- 
gether have  formed  a  diaphragm  closing  the  pupil.  The  pres- 
ence of  this  diaphragm  obliterates  vision,  although  light-per- 
ception and  projection,  perhaps,  may  be  very  good.  Such  a 
diaphragm  presents,  moreover,  a  serious  obstacle  to  the  current 
of  the  intraocular  fluids. 

After  the  cornea  has  been  incised  by  means  of  a  lance- 
knife  or  Graefe  knife  to  such,  an  extent  that  the  iridotomy- 
scissors  can  be  easily  introduced  into  the  anterior  chamber, 
the  scissors  are  entered  through  the  corneal  incision  and  their 
sharp  and  pointed  blade  is  thrust  through  the  diaphragm. 
Then  by  closing  the  scissors,  a  cut  is  made  without  appreciable 
dragging  on  the  ciliary  body. 

If  successfully  accomplished,  the  divided  tissues  retract,  open 
out  the  slit,  and  thus  a  pupil  is  established.  Sometimes  it  is 
necessary  to  make  a  second  cut  at  an  acute  angle  with  the  first 
and  thus  to  isolate  a  triangular  piece  of  tissue,  the  apex  of 
which  will  generally  either  curl  up  or  become  retracted,  and 
so  give  a  permanent  opening,  or  it  may  be  pulled  out  of  the 
eye  by  means  of  iris  forceps  and  be  cut  off. 


OPERATIONS.  '297 

Iridotomy  may  also  be  performed  in  various  other  ways,  as 
for  instance,  with  a  sharp  narrow  knife,  like  Graefe's  cataract 
knife,  Culbertson' s  iritome,  or  better  with  a  knife  needle. 
When  using  a  knife-needle  it  is  also  possible  to  avoid  drag- 
ging upon  the  ciliary  body,  and  we  dispense  with  bringing  so 
large  an  instrument  as  the  iridotomy-scissors,  or  the  iritome 
into  the  eyeball. 

§178.  Extraction  of  cataract.  What  is  usually  described 
as  simple  linear  extraction  is  applicable  particularly  to  soft  and 
traumatic  cataracts.  (See  Fig.  128).  In  such  cases  a  small 
incision  is  made  into  the  cornea  near  the  point  corresponding 
to  the  edge  of  a  dilated  pupil.  If  the  lens  capsule  has  pre- 
viously not,  or  insufficiently,  been  opened,  this  is  now  done  by 
means  of  a  cystotome.  The  soft  lens  substance  is  then  easily 
squeezed  out  through  the  corneal  wound.  In  a  similar  man- 
ner shrunken  and  membranous  cataracts  may  sometimes  be 
drawn  out  of  the  eye  with  a  small  hook. 


Fig.  128. — Corneal  incision  in  simple  linear  extraction  of  cataract. 

For  the  extraction  of  senile  cataracts  a  nuniber  of  proced- 
ures are  in  use.  They  differ  from  each  other  particularly  in 
the  position  of  the  corneal  incision  and  may  be  combined 
with  an  iridectomy  or  be  done  without  it,  or  when  an  iridect- 
omy is  made,  this  may  differ  in  size.  > 

Daviel ' s  method,  improved  by  Beer,  was  to  make  a  large 
corneal  flap,  the  incision  lying  in  the  lower  periphery  and 
comprising  about  one-half  of  the  circumference  of  the  cornea. 
Then  the  anterior  lens  capsule  was  opened  by  a  small  hook 
or  needle  and  the  lens  squeezed  out. 

This  operation  left  the  iris  untouched,  and  when  the  wound 
healed  without  an  accident,  a  round  moveable  pupil  was  left 
behind.  This  method  was,  for  a  long  time,  the  generally 
adopted  one.     As  asepsis  and  antisepsis   were  unknown,  and 


298  OPHTHALMOLOGY. 

local  anaesthesia  not  in  existence,  a  comparatively  large  per- 
centage of  eyes  so  operated  upon  were  lost  by  suppuration 
and  by  accidents  during  the  operation. 

Von  Graefe,  convinced  that  wounds  in  the  sclerotic  tissue 
would  heal  easier  and  when  made  linear  (in  the  line  of  a  great- 
est circle)  would  not  gape,  but  would  close  readily,  introduced 
the  section  which  lay  totally  in  the  tissue  of  the  corneo-scle- 
ral  margin.  (See  Fig.  129).  To  be  able  to  make  a  section 
large  enough  to  allow  of  the  passage  of  a  very  large  lens  he 
replaced  the  knives  hitherto  in  use.  {Beer's  triangular  knife  and 
the  lance-knife)  by  the  narrow  bladed  straight  knife  which 
bears  his  name.  He,  furthermore,  added  an  iridectomy,  which 
not  only  rendered  the  exit  of  the  lens  easier,  but  was  also 
thought  to  prevent  prolapse  of  the  iris  with  its  disagreeable 
consequences  [modified  von  Graefe  extraction).  In  finishing 
the  scleral  section  a  conjunctival  flap  could  be  made.  Then 
followed  opening  of  the  lens  capsule  and  squeezing  out  of  the 
cataract. 


Fig.  129. — The  ideal  corneo-scleral  incision  in  Von   Graefe's  method  of  extracting 
cataract. 

The  healing  after  this  method,  which  in  turn  was  slightly 
modified  by  most  operators  so  as  to  bring  the  height  of  the 
section  into  the  corneal  tissue,,  was  considerably  better  than  after 
the  old  flap  extraction.  Suppuration  of  the  wound  occurred 
in  comparison  but  rarely.  It  was,  therefore,  until  recently, 
and  with  some  still  is,  the  only  method  of  extracting  a  cat- 
aract. 

Aseptic  and  antiseptic  methods  and  the  local  anaesthesia 
produced  by  cocaine,  made  the  operation  more  free  from  acci- 
dents during  its   performance   and  afterwards.      The    aseptic 


OPERATIONS.  299 

and  antiseptic  measures  were,  further,  supplemented  by  the 
washing  out  of  the  lens  capsule  and  anterior  chamber  after 
the  extraction  of  the  lens  [McKeoivn),  and  some  surgeons  have 
adopted  this  maneouvre  as  a  routine  performance. 

The  chief  blemish  of  von  Graefe's  modified  extraction  is 
the  iridectomy,  which  mames  the  eye,  and  by  allowing  an  un- 
due amount  of  diffuse  light  to  enter  an  almost  immoveable  pu- 
pil often  reduces  the  visual  acuity. 


Fig,  130. — Corneal  incision  (corneal  flap)  in  simple  extraction  of  cataract. 

Most  ophthalmic  surgeons,  therefore  (See  Fig.  130),  have 
now  returned  to  an  operation  without  iridectomy  and  make, 
in  consequence,  a  corneal  flap,  comprising  about  one-third  of 
the  circumference  of  the  cornea.     (See  Fig.  131).     After   this 


Fig.  131. — Ml  dern  simple  exraciion  of  cataract  (corneal  flap,  no  iridectomy). 

follows  the  opening  of  the  lens  capsule  and  squeezing  out  of  the 
lens  substance.  This  in  turn  is  followed  by  replacing  the  iris 
and  the  instillatton  of  eserine.  This  method  is  now  called 
simple  extractio7i.  The  advantages  it  offers  and  the  ease  with 
which  healing  takes  place  in  these  days  of  asepsis  and  an- 
tisepsis, make  it  the  inethod  of  cataract  extraction  of  the 
future. 

§180.  Discission  of  the  anterior  lens-cap  stile. — la  order  to  bring 
the  lens-substance  in  contact  with  the  aqueous  humor   and  to 


300  OPHTHALMOL  OGY. 

thus  cause  its  gradual  dissolution  and  absorption  within  the 
eyeball,  we  must  divide  the  anterior  lens-capsule  and  the  lens- 
substance.  This  may  be  done  in  most  cases  of  cataract  in 
persons  under  the  age  of  30  years.  The  little  operation  is 
generally  executed  with  a  needle,  and  it  must  usually  be  re- 
peated several  times  before  a  perfect  success  is  reached.  Care 
must  be  taken  not  to  wound  the  iris,  and  to  make  the  first  di- 
vision of  the  capsule  very  small,  as  the  too  rapid  swelling  of 
the  lens-substance  may  give  rise  to  glaucomatous  symptoms. 
A  similar  operation  has  to  be  performed  after  the  extraction 
of  a  cataract  when  the  lens-capsule  remains  clouded  (second- 
ary cataract),  and  so  interferes  with  the  perfect  restoration  of 
vision. 

§181.  Pterygium  operations.  To  remove  a  small  pterygium 
successfully  it  is  usually  sufficient  to  separate  it  carefully  from 
the  cornea  and  sclerotic,  and  to  excise  with  it  a  little  of  the 
conjunctival  tissue  so  as  to  leave  a  wound  of  an  approximate- 
ly rhomboidal  shape.  The  conjunctiva  can  then  be  stitched 
together  to  cover  the  denuded  sclerotic. 

For  large  pterygia  this  simple  little  operation  is  also  perfect- 
ly as  successful  as  others,  when  the  wound  is  cauterized  (I  use 
pure  carbolic  acid)  after  the  dissection  and  the  conjunctival 
sack  is  flushed  subsequently  for  some  weeks  several  times  a 
day  by  a  solution  of  bichloride  of  mercury.  I  have  of  late 
discarded  the  stitching  of  the  conjunctival  wound  lips  alto- 
gether, but  usually  incise  the  conjunctiva  near  the  cornea  ad- 
joining the  site  of  the  pterygium  in  such  a  manner  as  to  allow 
it  to  withdraw  from  the  cornea.  By  this  means  the  corneal 
wound  is  healed  over  before  the  conjunctival  loss  of  substance 
is  replaced,  and  the  result  is  better. 

Prince  recommends  to  tear  the  pterygium  from  its  corneal 
attachment,  and  claims  that  the  cornea  is  finally  clearer  than 
when  abscision  has  been  made. 

For  large  pterygia  several  other  methods  are  in  use.  The 
whole  pterygium,  after  having  been  cut  off  the  cornea  and 
sclerotic,  can  be  transplanted  into  the  fornix  of  the  conjuncti- 
va where  an  incision  has  been  made  to  receive  it  {^Desmarres). 
This  has   been    improved    upon  by    Knapp  who,  after   having 


OPERATIONS.  301 

severed  the  pterygium  from  the  cornea  and  sclerotic  down  to 
its  base,  cuts  it  into  two  halves  from  point  to  base.  The  incis- 
ions into  the  conjunctiva  are  then  carried  further  upwards  and 
downwards  into  the  cul-de-sac,  and  when  this  is  done,  each 
half  of  the  pterygium  is  stitched  into  the  corresponding  gap 
resulting  from  these  incisions.  The  operation  yields  lasting 
results. 

A  simple  method  which  has  been  in  use  with  some  operat- 
ors for  many  years  {Galezowsky),  and  has  found  its  warm  ad- 
vocates, has  given  me  also  perfect  satisfaction.  It  is  done  in 
the  following  way:  After  the  pterygium  has  been  dissected 
from  the  cornea  and  sclerotic,  down  to  its  base,  the  conjuncti- 
va at  its  base  is  undermined,  so  that  the  whole  pterygium  can 
be  doubled  upon  itself  and  folded  under  it.  It  is  then  sewed 
to  the  conjunctiva  in  this  position,  and  finally  atrophies. 


Fig.  132. — Teale's  method  of  making  conjunctival  flaps  for  the  covering  of  the  ocular 
wound-surface  resulting  from  the  severing  of  a  symblepharon.  In  the 
lower  picture  the  flaps  are  in  position,  as  at  the  completion  of  the  opera- 
tion. 

§182.  Operations  for  the  cure  of  symblepharon.  A  small 
bridge-like  symblepharon  can  be  simply  divided  with  the  scis- 
sors, but  if  the  union  between  the  eyelid  and  the  eyeball 
reaches  far  down  into  the  fornix,  usually  more  must  be 
done  to  prevent  the  large  wound-surfaces  from  growing  to- 
gether again.     This    can    be   accomplished    by  transplanting 


302  OPHTHALMOLOGY. 

flaps  of  the  conjunctival  tissue  of  the  same  eye  upon  the  ocu- 
lar wound  surface  (See  Fig.  132),  or  by  transplanting  a  con- 
junctival flap  without  pedicle  from  another  human  or  animal's 
eye  upon  one  or  both  of  the  two  wound-surfaces.  Cutaneous 
flaps  have  also  been  successfully  made  use  of.  They  are  taken 
from  a  distant  part  (arm,  Kuhnt)  and  without  a  pedicle. 
They  may  also  be  taken  from  the  eyelid,  in  which  case  the 
skin  is  drawn  through  a  button-hole-like  aperture  made  in  the 
eyelid,  and    stitched  to    its  its  inner  surfuce. 

§183.     Ptosis  operations.     See  Chapter  III. 

§184.  Trichiasis  and  entropium  operations. — Among  the 
many  methods  recommended  for  the  cure  of  trichiasis  or  en- 
tropium of  the  eyelids  two  of  the  best  seem  to  be  those  that 
have   been  perfected  by  Gi'een  and  Hotz.     (See  Chapter  III). 

In  Green's  operation  the  conjunctiva  and  tarsal  tissues  are  cut 
through  in  a  horizontal  direction  parallel  to  the  lid-margin  and 
somewhat  removed  from  it  on  the  cutaneous  surface.  (See  Fig. 


Fig.  133. — (After  Green).  Shows  the  incision  through  the  conjunctiva  and  tarsal 
tissue  on  the  inner  side  of  the  upper  lid  in  Green's  operation  for  entro- 
pium and  trichiasis. 

133).  Then  a  narrow  strip  of  skin  is  removed  from  the  outer 
surface  of  the  eyelid  corresponding  to  the  tarsal  incision.  (See 
Fig.  134).  Then  sutures  are  put  in  in  the  following  manner:  a 
needle  armed  with  a  thread  is  entered  near  the  ciliary  margin 
and  is  brought  out  on  the  outer  surface  of  the  eyelid .  at  the 
lower  wound-lip,  and  after  gliding  along  on  the  tarsal  tissue,  it 


OPERATIONS.  303 


is  brought  out  again  through  muscle  and  skin.      The  ends  are 
then  tied.    Three  or  more  such  sutures  are  usually  required. 


Fig  134.— (After  Gieen).  Shows  the  excision  of  a  strip  of  skin  from  the  upper  lid  in 
Green's  operation  for  entropium  and  trichiasis. 

^  In  Hotz's  operation  an  incision  is  made  through  the  skin  and 
muscle  of  the  eyelid  along  the  orbital  edge  of  the  tarsus,  so 
as  to  lay  bare  the  tarso-orbital  aponeurosis.  Then  a  strip  of 
muscular  tissue  is  removed  and  sutures  (three  or  four)  are*  ap- 
plied in  the  following  way:  the  needle,  armed  with  a  thread,  is 
entered  at  the  lower  wound-lip  through  the  skin  and  aponeu- 
rosis, and  is  brought  out  again  through  aponeurosis  and  skin 
at  the  upper  wound-lip.  The  ends  are  then  tied  so  that  the 
skin  and  aponeurosis'may  heal  together. 

In  order  to  do  away  with  any  loss  of  substance  by  the  oper- 
ative interference,  it  has  been  recommended  {yon  Millmgen)  to. 
slit  the  lid-margin  in  two  along  its  border  so  as  to  form  two 
flaps,  the  outer  consisting  of  the  skin  and  cilia,  the  inner  of 
tarsus  and  conjunctiva,  and  to  implant  a  flap  of  skin  or  mucous 
membrane,  or  a  Thiersch  flap  {Gifford)  into  this  gap. 

§185.  Ectropium  operations. — Slight  ectropium  of  the  low- 
er eyehd  may  be  cured  by  Adams'  operation  (See  Chapter 
III),  or  by  removing  a  triangular  piece  from  the  tissue  adjoin- 
ing the  outer  angle  of  the  palpebral  fissure  (See  Fig.  135),  so 
that  the  apex  of  the  triangle  lies  somewhat  higher  than  this 
angle.     Into  the  apex  of  the  resulting  gap  the  lower  eyelid  is 


304         .  .  OPHTHALMOLOGY, 

then  drawn  and  stitched.  Kuhnt  recently  recommended  to  re- 
move a  triangular  piece  of  the  conjunctiva  and  tarsal  tissue, 
not  including  the  skin,  its  base  lying  at  the  ciliary  margin  ©f 
the  eyelid,  its  apex  in  the  fornix  of  the  conjunctiva.  This  in- 
cision is  followed  by  a  single  suture  through  the  whole  lid  near 
the  ciliary  margin. 


Fig.  135. — Excision  of  a  triangular  piece  of  tissue  from  the  cuter  canthus  for  the 
cure  of  ectropium. 

When  ectropium  is  caused  by  the  contraction  of  scar-tissue 
after  a  cut  or  a  deep  burn,  the  excision  of  this  scar-tissue  may 
sometimes  be  sufficient  to  cure  the  ectropium.  In  most  cases, 
however,  it  requires  a  more  extensive  operation,  and  usually 
the  transplantation  of  a  flap  or  flaps,  with  or  without  a  pedicle. 

§186.  Canthotomy  and  canthoplasty. — Shortening  of  the 
palpebral  fissure  sometimes  necessitates  a  surgical  interference. 
If  the  required  effect  need  not  be  very  large,  canthotomy  is 
made.  This  consists  in  cutting  through  the  tissues  forming 
.the  outer  commissure  of  the  eyelids  by  means  of  a  strong  pair 
of  scissors.  To  increase  the  effect  of  this  little  operation  the 
adjoining  conjunctiva  is  undermined,  and  then  stitched  into 
the  gap  resulting  from  the  cut  (canthoplasty).  Noyes  has  ad- 
vised a  more  effective  mode  of  canthoplasty.  The  canthoto- 
my being  made,  the  section  through  the  outer  canthus  is  car- 
ried further  on  towards  the  temple.  Then  a  small  flap  of  skin 
with  its  pedicle  at  the  end  of  this  cut  is  dissected  and  twisted, 
so  as  to  fit  into  the^gap  caused  by  the  incision. 

A  description  of  the  various  methods  for  partial  or  total 
blepharoplasty  may  be  found  in  any  modern  text-book  on  oper- 
ative surgery. 


CHAPTER  XXVII.— ON  SPECTACLES. 

§187.  The  best  material  for  spectacle  glasses  is  crown-glass, 
which  is  made  by  the  fusion  of  white  sand  120  parts,  carbon- 
ate of  potassium  35  parts,  carbonate  of  sodium  26  parts, 
slaked  lime  or  chalk  20  parts,  and  arsenic  i  part.  Flint  glass 
is  heavier  and  softer.  It  consists  of  sand  42.5  parts,  oxide  of 
lead  43.5  parts,  carbonate  of  potassium  1 1.7  parts,  nitrate  of 
potassium  1.8  parts,  and  chalk  0.5  parts  {Bohne).  Another 
material  from  which  spectacle  lenses  are  made  is  rock-crystal, 
commonly  called  pebbles.  This  is  harder  than  glass,  and 
consequently  does  not  get  scratched  as  easily. 

Lenses  are  made  by  grinding  a  block  of  glass  on  tools  which 
are  segments  of  a  sphere,  or  a  cylinder,  or  a  torus,  to  the  de- 
sired curvature. 

We  have,  accordingly,  convex  spherical,  concave  spherical, 
convex  cylindrical,  concove  cylindrical,  or  combinations  of  these, 
and  toric  lenses.  When  a  lens  is  convex  (or  concave)  on  one 
side  and  flat  on  the  other  it  is  called  plano-convex  or  piano- 
concave;  when  it  is  convex  (or  concave)  on  both  sides,  it  is 
called  bi-co7ivex  (or  bi-concave).  In  another  form  of  lenses 
called  meniscus  or  periscopic  lenses,  one  side  is  convex  and  the 
other  concave  (concavo  convex  lens).  When  one  surface  is 
plane  and  the  other  cylindrical,  we  speak  of  a  piano- cylindrical 
lens;  when  one  side  is  spherical  and  the  other  cylindrical,  it  is 
called  a  sphero-cylifidrical  lens.  Toric  lenses  have  two  crossed 
cylinders  of  unequal  radius  ground  on  one  side,  while  the  other 
side  may  be  plane  or  spherical  (convex  or  concave).  They  are 
obtained  by  grinding  the  glass  by  means  of  a  wheel  the  pe- 
riphery of  which  has  a  curved  (convex  or  concave)  surface. 

Another  form  of  glasses  which  are  sometimes  made  use  of 
in  spectacles  alone  or  in  combination  with  spherical  or  cylin- 
drical surfaces,  are  prismatic  glasses. 

§188.     Prisms  refract  the  rays  passing  through    them  toward 

—305— 


sot)  OPHTHALMOLOGY. 

their  base,  in  consequence  objects  seen  through  them  are  ap- 
parently displaced  from  their  real  position.  Spherical  lenses 
may  be  considered  as  combinations  of  two  prisms;  in  the  bi- 
convex glass  these  prisms  lie  together  with  their  bases,  in  the 
bi-concave  lens  they  lie  together  with  their  refracting  angles. 
Thus  a  bi-convex  lens,  refracting  the  rays  towards  the  joint 
bases,  renders  them  more  convergent,  while  a  bi-concave  lens 
renders  the  rays  passing  through  it  less  convergent  or  actually 
divergent,  according  to  the  larger  or  smaller  distance  of  their 
source  from  the  lens.  The  refracting  action  of  cylindrical  sur- 
faces is  the  same,  but  only  in  the.  one  meridian  which  stands 
at  right  angles  to  their  axis. 

§189.    From  the  foregoing  the  action  and  value  of  different 
forms  of  spectacle  lenses  may  be  readily  understood. 


Fig.  136. — The  upper  figure  shows  the  manner  in  which  parallel  rays  are  focussed  by  a 
hypermetropic  eye  behind  its  retina;  the  lower  one  shows  the  manner  in 
which  a  convex  lens  alters  the  course  of  parallel  rays  so  that  they  are 
focussed  on  the  retina. 

According  to  what  was  stated  in  Chapter  XX,  a  hyperme- 
tropic eye  is  too  short  to  be  able  to  focus  parallel  rays  on  the 
retina  (See  Fig.  136),  and  in  consequence  its  retina  lies  in  front 
of  the  focus  for  parallel  rays.  A  glass  held  in  front  of  the 
eyes  which  will  render  the   parallel    rays   more  convergent,  so 


ON  SPECTACLES.  307 

as  to  bring  their  focus  into  the  plane  of  the  retina,  will  render 
this  hypermetropic  eye  practically  emmetropic.  This  is  done 
by  means  of  a  convex  lens. 

In  the  same  way,  a  concave  lens  will  render  a  myopic  eye 
practically  ejnmetropic.  A  myopic  eye  is  too  long  to  be  able  to 
focus  parallel  rays  on  its  retina.  (See  Fig.  137).  Its  retina, 
therefore,  Hes  behind  the  focus  for  parallel  rays.  A  glass, 
which,  held  before  the  eye,  will  render  parallel  rays  so  diverg- 
ent that  by  the  refraction  of  the  eye  their  focus  is  just  brought 
into  the  plane  of  the  retina  of  the  myopic  eye,  will  correct  the 
myopia.     This  must  be  a  concave  glass. 


Fig.  137. — The  upper  figure  shows  how  parallel  rays  are  focassed  by  a  myopic 
eye  in  front  of  its  retina;  the  lower  figure  shows,  how  a  concave  lens 
alters  the  course  of  parallel  rays,  so  as  to  be  focussed  on  the  retina  of  the 
myopic  eye. 

Cylindrical  lenses  have  their  place  in  the  correction  of  astig- 
matism. As  has  been  detailed,  an  astigmatic  eye  has  a  cornea 
which  is  curved  asymmetrically.  In  the  regular  forms  of  as- 
tigmatism we  have  two  so-called  principal  meridians  which 
practically  stand  at  right  angles  to  each  other,  and  one  of 
which  is  the  most  while  the  other  is  the  least  curved  one. 

To  render  such  an  eye  emmetropic  we  either  must  add  to 
the  refraction  of  the  meridian  of  least  curvature  or  reduce  the 
refractive  power  of  the  meridian  of  highest  curvature.  Glasses 


308  OPHTHALMOLOGY. 

which  correct  in  one  meridian  only  are  cylindrical  lenses.  A 
cylindrical  lens  of  the  proper  refracting  power  placed  before 
the  eye  with  its  axis  at  right  angles  to  the  position  of  the  me- 
ridian, the  refraction  of  which  is  to  be  corrected,  must  bring 
about  the  desired  result. 

If  an  eye  is  built  too  short  or  too  long,  and  has,  moreover, 
an  asymmetrically  curved  cornea,  a  combination  of  a  cylindri- 
cal surface  on  the  one  side  with  a  spherical  one  on  the  other 
side  has  to  be  made. 

In  presbyopia,  the  power  of  accommodation  for  near  ob- 
jects is  wanting  on  account  of  the  inability  to  make  the  crys- 
talline lens  convex  enough  through  the  action  of  the  ciliary 
muscle.  This  means  that  the  eye  cannot  render  by  its  inherent 
faculty  divergent  rays,  coming  from  near  objects,  convergent 
enough  to  bring  their  focus  in  the  plane  of  the  retina.  This 
faculty  can  be  equaled  to  a  convex  lens  of  such  power  as  to 
focus  divergent  rays  on  the   retina.     (See  Fig.  1 38J.     Conse- 


FlG.  138. — The  (light)  meniscus  added  to  the  (dark)  crystalline  lens  represents  the 
increase  in  its  convexity  during  the  act  of  accommodation.  In  presbyopia 
the  crystalline  lens  cannot  assume  the  convexity  necessary  for  seeing  near 
objects  clearly.  This  lack  of  accommodation  can  be  supplemented  by 
putting  a  convex  lens  before  the  eye  (which  takes  the  place  of  the  menis- 
cus added  to  the  crystalline  lens  when  it  can  accommodate). 

quently  such  a  convex  lens  held  before  the  eye  will  remedy 
presbyopia  and  enable  the  eye  to  see  near  objects  plainly.  The 
correcting  lens  for  presbyopia  in  ametropic  eyes  of  whatever 
degree  and  form  must  therefore,  for  near  work,  be  added  to 
the  glass  worn  for  distant  vision. 

In  order  to  do  away  with  the  necessity  of  changing  the 
glasses  according  to  the  near  or  far  use  they  are  put  to,  several 
kinds  of  glasses  have  been  devised  in  which  the  two  lenses  are 


ON  SPECTACLES, 


combined  in  one  frame,  so  that  the  upper  portion  is  the  glass 
for  the  distant  and  the  lower  one  the  glass  for  near  vision  (two 
half  lenses,  Franklin  glasses,  the  presbyopic  lens  pasted  on 
the  far  lens  or  ground  into  it). 


Fig.  139. — A  prism  placed  before  one  eye  with  the  base  towards  the  temple  will  dis- 
place its  image  in  such  a  manner  as  to  cause  heteronymous  diplopia. 
The  right  image  belongs  to  the  left  eye  and  the  left  image  to  the  right 
eye.  This  is  the  manner  in  which  a  prism  may  correct  diplopia  due  to 
divergence. 

§190.  Prismatic  glasses,  by  their  power  of  displacing  the 
object  looked  at,  may  be  made  use  of  to  correct  diplopia.  (See 
Fig.  139).  A  prism  held  before  one  eye  with  the  base  outward 
will  cause  crossed  (heteronymous)  diplopia;  a  prism  held  be- 
fore one  eye  with  the  base  inward  will  cause  homonymus  dip- 
lopia. (See  Fig.  140).  This  is  due  to  the  fact  that  we  project 
impressions  received  by  the  brain  through  the  retina  outward 
in  the  same  direction  in  which  they  have  come  to  the  brain. 
An  object  looked  at  through  a  prism  appears,  therefore,  to  be 
displaced  in  the  direction  of  the  prolongation  of  the  refracted 
rays.  When  looking  through  a  prism  thi^  means  that  we  see 
the  object  displaced  toward  the  refracting  angle  or  apex  of  the 
prism.  We  can,  therefore,  reduce  double  vision,  caused  by 
paresis  or  paralysis  of  a  muscle,  to  single  vision  by  placing  a 
prism  before  the  affected  eye  in  such  a  manner  as  to  neutral- 
ize the  apparent  displacement  of  objects  looked  at. 

In  the  same  manner  we  may  in  the  case  of  insufficiency  of  a 
muscle  supplement  its    deficient   action  by   means  of  a  prism, 


310 


OPHTHALMOLOG  V. 


and,  by  not  fully  correcting  it,  help  to  strengthen  such  a  mus- 
cle. 

In  conical  cornea  hyperbolic  lenses,  introduced   by   Raehl- 
mann^  have  sometimes  been  found  very  valuable. 


Fig.  140. — A  prism  with  the  base  towards  the  nose  held  before  one  eye  will  displace 
its  image  in  such  a  manner  as  to  cause  homonymous  diplopia.  The  right 
image  belongs  to  the  right  eye  and  the  left  image  to  the  left  eye.  This  is 
the  manner  in  which  a  prism  may  correct  diplopia  due  to  convergence. 

§191.  Spectacles  may  be  used  also  to  simply  protect  an  eye 
from  the  irritating  rays  of  light,  or  from  foreign  substances 
apt  to  strike  the  eye  deleteriousl/. 

The  former  indication  may  be  met  by  the  use  of  smoke  or 
blue  glasses.  Plain  large-sized  glasses  are  preferable  to  the 
curved  ones  which  are  often  used.  The  curved  glasses  have 
but  very  seldom  {Eaton)  parallel  surfaces,  but  are  more  often 
concave  or  concave  cylindrical  and,  therefore,  may  be  decid- 
edly damaging.  The  coquilles  with  wire-netting  should  not 
be  used  at  all,  especially  not  in  order  to  protect  an  inflamed 
eye,  as  they  retain  too  much  heat  and  prevent  ventilation. 

Workmen  whose  eyes  are  exposed  to  flying  chips  of  metal 
or  stone  should  wear  protective  spectacles  made  of  mica,  which 
are  far  superior  to  the  wire-shields  they  sometimes  use,  since 
they  allow  of  almost  accurate  vision  and  are  tough  enough  to 
withstand  a  considerable  amount  of  force. 


CHAPTER    XXVIII.— THE  DRUGS    MOST   COMMON- 
LY   USED    IN    OPHTHALMIC     PRACTICE. 

§192.  In  order  to  produce  mydriasis  and  paralysis  of  the 
accommodation,  the  chief  drug  is  the  sulphate  of  atropia.  The 
physician,  in  prescribing  it,  ought  to  be  sure  that  his  druggist 
actually  has  the  neutral  salt,  sulphate  of  atropia,  in  stock,  and 
does  not — as  too  often  happens— simply'  dissolve  atropia  by 
means  of  sulphuric  acid.  A  solution  ^of  atropia  made  with 
sulphuric  acid  is  almost  never  perfectly  neutral,  and  when  the 
acid  is  in  excess  its  instillation  causes  severe  pain.  To  detect 
its  acidity  it  may  sometimes  be  necessary  to  allow  the  litmus- 
paper  to  remain  in  the  solution  for  several  hours. 

IBji     Atropiae    sulphatis  neutr.,  -  grs.  ij  to  iv. 

4%  Sol.  acid  boracic,     -         -  -         -         5j. 

Sig.     To  be  dropped  into  the  eye. 

It  will  depend  on  the  aim  of  the  physician  in  the  case  in 
hand,  how  strong  the  solution  must  be,  and  how  often  it  will 
have  to  be  instilled.  When  complete  paralysis  of  the  ciliary 
muscle  is  desired  for  any  reason,  and  in  cases  of  iritis  the 
strongest  solution,  grs.  iv  to  5j,  should  be  used,  and  the  num- 
ber and  interval  between  the  instillations  is  to  be  regulated 
according  to  necessity  of  the  case,  or  in  iritis  to  the  severity 
of  the  inflammation,  and  the  firmness  of  adhesions  which 
may  have  been  formed  between  the  iris  and  the  anterior  lens- 
capsule. 

For  milder  cases,  for  the  examination  of  the  back-ground  of 
the  eye,  or  for  determining  an  error  of  refraction,  etc.,  the  less 
poisonous  and  milder  mydriatic,  hydrobromate  of  homatro- 
pine,  has  come  into  use.  The  form  in  which  it  is  prescribed  is 
the  following: 

I(^     Homatropin.  hydrobromat.,         -  grs.  ij  to  iv. 

4%  Sol.  acid  boracic,     -         -  -         -         5ij. 

Sig.     To  be  dropped  into  the  eye. 

—^11— 


312  OPHTHALMOLOGY. 

Both  mydriatics  may  be  used  in  the  form  of  gelatine  disks, 
or  in  solution  in  castor  oil,  or  in  the  form  of  an  ointment,  and 
it  is  claimed  that  the  effect  of  the  mydriatic  is  greater  and 
the  quantity  needed  consequently  smaller  when  so  applied. 

When  the  atropine  is  not  well  borne  by  the  patient  and 
causes  symptoms  of  poisoning,  it  has  long  been  recommended 
to  use  in  its  stead  the  extract  of  belladonna. 

'Sf     Extract.  Belladonn.,       -  -  .  grs.  v. 

Aq.  destillat.,  -  _  .  _  §ss. 

Filter  well. 

Hyoscyamine,  datuilne  and  duboisine,  which  have  been  re- 
commended as  substitutes  for  atropine,  seem  to  be  in  reality 
practically  identical  with  this  alkaloid. 

A  more  effectual  mydriatic  than  atropine  is  found  in  hyos- 
cine,  which,  however,  causes  often  a  general  intoxication. 

^      Hyoscin.  hydroiod.,  -  _  .         grs.  ij. 

4%  Sol.  acid,  boracic,  _         -  _         §ss. 

Among  the  miotics  (remedies  which  contract  the  pupil) 
eserine  holds  the  first  place. 

^      Eserin.  sulph.  neutr.,  or  eserin  salicyl.,  grs.  j  to  ij. 
Aq.  destillat.,  .  .  _  .  §ss. 

Solutions  of  eserine  when  standing  for  some  time,  especially 
when  exposed  to  light,  turn  brown-red.  Such  solutions,  how- 
ever, act  as  well  and  are  not  spoiled.  A  weaker  effect  maybe 
reached  by  a  72%  solution  of  the  muriate  of  pilocarpine. 

Local  anaesthesia  is  produced  by  cocaine  (or  tropa-cocaine). 
This  drug  may  also  with  advantage  be  added  to  the  atropine 
solution  in  iritis  and  painful  keratitis,  and  by  its  mild  mydriatic 
action  is  often  sufficient  for  the  examination  of  the  fundus  of 
the  eye. 

!l^      Cocain.  hydrochlor.,         -  -  .  grs.  v. 

4%   Sol.  acid,  boracic,         -  -  -  31;. 


DRUGS.  313 

§193.  For  producing  local  antisepsis  or  a  certain  degree  of 
asepsis,  we  use  bichloride  of  mercury,  chlorinated  water,  boracic 
acid,  pyoktanine,  iodoform,  aristol,  and  other  drugs. 

^,      Hydrarg.  bichlor.,  .  ~-  _  gr.  ^j^. 

Aq.  destillat.,  -  -  -  -  Sv. 

Sig.     To  be  poured  into  the  eye  three  or  four  times  a  day. 

'Bfi     Aq.   chlor.,  -  -  -  -  -  Sj. 

D.     In  a  dark  bottle. 

Sig.     To  be  dropped  into  the  eye. 

'S^     Acid,  boracic,       -         -  -  -         -  5j. 

Aq.  destillat.,  _  _         -         _         .     §iij. 

Sig.     To  be  poured  into  the  eye  every   two   or  three  hours. 

!^tf     Pyoktan.,         -----  gr.  j. 

Aq.  destillat.,       -         -  -  -  -         Sj. 

Sig.     To  be  dropped  into  the  eye. 

This  solution  is  very  useful,  if  disagreeable,  in  affections  of 
the  lachrymal  drainage  apparatus. 

Iodoform  may  be  used  in  the  form  of  an  impalpable  powder 
strewed  into  the  eye,  or  in  the  shape  of  an  ointment. 

^     Iodoform.,         -         -         -         -         grs.  x  to  xx. 
Vasel.  alb.,  -----  5ss. 

Sig.     To  be  rubbed  into  the  eye  once  a  day. 

Aristol  may  also  be  used  as  a  powder  or  in  the  form  of  an 
ointment. 

IB^     Aristol.,         -----  grs.  xx. 

Vasel.  alb.,         -----  5iij. 

M.     Sig.     To  be  rubbed  into  the  eye  once  a  day. 

§194.  When  an  astringent  action  is  desired  sulphate  of  zinc 
answers  the  purpose  best  for  milder  action.  If  a  stronger 
and  superficial  caustic  action  is  desired,  nitrate  of  silver  is  in 
its  place.     While  the  application  of  the  zinc  solution   may,  if 


314  OPHTHALMOLOGY. 

desired,  be  safely  left  to  the  patient,  the  physician  should  ap- 
ply the  nitrate  of  silver  always  himself. 

^     Zinc,  sulph.,  -  r  -  -  grs.  v. 

Aq.  destillat.,  -  -  -  -  §j. 

To  be  brushed  on  the  inside  of  the  lower  lids  every  morn- 
ing. 

^     Argent,  nitr.,  -  -  -  -  grs.  v. 

Aq.  destillat.,     -         -  -  -  -  Sj. 

Sig.     To  be  brushed  on  the  inside  of  the  Uds  once  a  day. 

In  the  treatment  of  trachoma  sulphate  of  copper  is  the  sov- 
ereign remedy  (after  squeezing  out  the  granules).  It  is  best 
used  in  the  form  of  the  pure  crystal.  Nicely  shaped,  smooth 
and  round  sticks  can  now  be  obtained  ready-made  at  the  drug- 
gist's. 

§195.  Ointments,  of  which  various  ones  may  be  made  use 
of  in  the  treatment  of  external  eye  diseases,  are  best  made 
with  white  vaseline.  The  common  yellow  vaseline  is  often 
acid  and  irritating. 

ISf     Hydrarg.  ox.  flav.,         -         -         -      grs.  ij  to  iv. 
Vasel.  alb.,       ->----       5iij. 
M.     Sig.    To  be  rubbed  into  the  eyes. 

This  ointment  of  yellow  oxide  of  mercury,  which  is  very  fre- 
quently used  in  ophthalmic  practice,  is  better  than  a  similar 
one  made  of  the  red  oxide  of  mercury,  as  the  yellow  oxide  is 
an  impalpable  powder.  It  must  be  so  well  mixed  that  no  little 
grains  or,  worse  yet,  lumps  of  the  powder  can  be  seen  in  it. 
An  ointment  which  is  npt  well  mixed  is  apt  to  cause  a  great 
deal  of  undue  irritation  and  even  ulceration. 

Instead  of  white  vaseline  some  prefer  lanoline  (wool-fat). 
My  experiences  with  it  have  led  me  to  discard  its  use  years 
ago. 

§196.  There  are  three  more  remedies  which  are  applied  in  the 
form   of  a  powder.     Calomel  {hydrarg.  chlor.  mite),   iodoform 


DRUGS,  315 

dindjequirity.  Their  use  has  been  fully  detailed  in  the  chap- 
ters on  the  affections  of  the  cornea  and  conjunctiva. 

When  it  is  desirable  to  create  a  vigorous  diaphoresis,  extract 
of  jaborandi  may  be  given  internally.  It  is,  however,  better 
generally  to  use  the  alkaloid  pilocarpine  derived  from  it,  in  the 
form  of  the  muriate  of  pilocarpine,  for  subcutaneous  injections. 
It  is  always  well  first  to  give  the  patient  a  stimulant,  and  then 
inject  the  solution  of  pilocarpine  muriate.  I  usually  begin 
with  gr.  7io  and  increase  the  dose  every  day  until  disagreeable 
symptoms,  as  nausea  and  vomiting  appear.  This  happens 
with  most  otherwise  healthy  people  when  gr.  7*  or  Va  ^^^  been 
injected,  while  others  cannot  stand  more  than  gr.  Yt  or  Vs- 

As  adjuvants  to  the  medicinal  treatment  in  eye-affections 
we  make  use  of  heat,  cold,  natural  and  artificial  leeches,  mas- 
sage, and  the  galvanic  current. 


IISTDE^L. 


ABSCESS  of  the  cornea 128 

of  the  eyelid,  phlegmonous          -----  49 

Abscision  of  a  corneal  staphyloma                -----  293 

Accommodation,  Faculty  of  changing  the  focus  of  the  eye,              -            -  228 

Examination  of     -----            -  39 

Accommodative  apparatus.  Ciliary  muscles  and  crystalline  lens    -            -  290 

Acuteness  of  vision,  Examination  of            -            -            -  ^         -            -  36 

Adenoma  of  the  lachrymal  gland      ------  65 

Advancement  of  the  internal  rectus  for  divergent  squint    -            -            -  290 

of  Tenon's  capsule      ------  291 

Albinism,  Lack  of  pigment  in  the  cells  of  the  uveal  tract  and  pigmentary 

epithelium          --------  14 

Albuminuria              -            -            .            -             .            _            -            _  275 

Amaurosis,  Blindness  from  disease  of  the  background  of  the  eye               -  182 
Amaurotic  cat's  eye,  Peculiar  appearance  of  an  eye  affected  with  glioma  of 

the  retina            --------  175 

Amblyopia,  Reduced  vision              ------  182 

Ametropia,  Condition  in  which  an  eye  at  rest  is  not  focussed  for  parallel 

rays        ---------  174 

Amyloid  degeneration  of  the  conjunctiva     -            -            -            -            -  US 

Anaemia  of  the  bram,             -------  258 

of  the  optic  nerve  and  retina          -            -            -            -            -  177 

pernicious.  Progressive       ------  273 

Anaesthesia  of  the  cornea  from  glaucoma    -----  202 

paralysis  of  the  fifth  nerve               -           -  133 
Anchyloblepharon,  Adhesion  between  the  lid-margins  or  between  the  eye- 
lids and  eyeball              -            -            -            -            -            -            -  116 

Aneurism  of  the  ophthalmic  artery               -----  274 

Angioma  of  the  eyelid          -------  53 

Aniridia         ---------  268 

Anisometropia           -            -            -            -            -            ■            -            -  239 

Anterior  chamber.  Space  bounded  by  the  cornea,  iris  and  anterior  lens- 
capsule                --------  25 

Antisepsis  and  asepsis           -------  287 

Aphakia,  Absence  of  the  crystalline  lens     -            -            -            -            -  195 

Aqua  chlori,  Use  of               -            -            -            -            -            -            -  313 

Aqueous  humor,  Contents  of  the  anterior  and  posterior  chambers  of  the 

eye 25 

Arachnoid  sheath  of  the  optic  nerve            -----  20 
Arcus  senilis.  Fatty  degeneration  of  the  tissue  in  the  periphery  of  the 

cornea    ---------  135 

—317— 


318  OPHTHALMOLOGY. 

Argyll  Robertson  pupil        -..-_--  182 

Aristol,  Use  of--------  287 

Artery,  Central  retinal          -            -            -            --            -            -  24 

Artificial  eye,  Insertion  of  an            -            -           -           -            -            -  59 

Artificial  vitreous  body  -  -  -  -  --  -217 

Assistance  in  eye-operations            ______  91 

Astigmatism,  Condition  in  which  the  meridians  of  the  cornea  (or  lens)  are 

of  different  radii                _            .            _            _            _  237 

Compound      -_-----  184 

Irregular          _______  184 

Mixed 184 

Regular           .            _            .            _            .            _            -  184 
Asthenopia,  Weakness  caused  by  the  strain  on  the  accommodative  appa- 
ratus from  hypermetropia             -            _            -            _  232 
Of  the  internal  recti  from  myopia      _            _            -            -  236 
From  presbyopia        -            -            -            -            -            -  241 

Astringents,  Use  of               _______  84 

Atrophy  of  the  optic  nerve  after  neuritis       -            -            -            -            -  1 78 

Genuine,  progressive     -           -            -            -  180 

Atropia,  Use  of  the  sulphate  of         -            -            -            -            -            -  311 

BANDAGING  eyes -            -  89 

Basedow's  disease,  Exophthalmus,  goitre  and  palpitations  of  the  heart     -  276 

Belladonna,  Use  of  the  extract         -           -           -            -            -            -  312 

Bichloride  of  mercury,  Use  of          ____.-  313 

Blepharitis  ciliaris,  Inflammation  of  the  lid-margin             -           -           -  45 

Blepharoplasty,         ----.-_-  51 

Blepharophimosis,  Shortening  of  the  palpebral  fissure        .            _            -  61 

Blepharospasmus,  Spastic  closure  of  the  eyelids,  Clonic     -           -            -  59 

Tonic      -            -           -  60 

Blood-supply  of  orbit  and  eye           -            .            -                         -            -  27 

Bone-formation  in  the  choroid         -           -            -            -            -           -  162 

Boracic  acid,  Use  of             ____.--  313 

Bowman's  layer  of  the  cornea           -            -     '^       -            -            -            -  10 

Bowman's  probes  for  dilating  strictures  of  the  lachrymal  apparatus            -  71 

Burns  of  the  conjunctiva       -            -            -            -            -            -            -  114 

Cornea             ____..-  138 

Eyelid               --...__  63 

Buphthalmus             -           -           -           -           --           -           -  267 

CANALIS  opticus,  bhort  canal  through  which  the  optic  nerve  enters  the 

orbit       _--_._-.--  3 

Canthoplasty,  Insertion  of  a  twisted  cutaneous  flap  into  the  outer  angle  of 

the  palpebral  fissure       -            -            --            -            -            -  61 

Canthotomy,  Incision  through  the  outer  commissure  of  the  eyelids           -  61 

Canthus,  Angle  of  the  palpebral  fissure        -----  5 

Caries  of  the  orbital  walls    -            -            -            -            --            -  75 

Cataract,  Opacity  of  the  crystalline  lens      _           -            -                        -  184 

Acquired                -            -            -,            -            -            -            -  187 

Complicated           -            -            -            -            -            -            -  189 


INDEX.  819 

Cataract,  Congenital              -            -            -.-            -            -            -  184 

Cortical      -            -                        188 

Diabetic     --------  159 

Fluid           ...----.  188 

Hard  (nuclear,  senile)        -            -            -            -            -            -  189 

Hypermature  (over-ripe)               -            -            -            -            -  187 

Immature  (unripe)             -----  187 

Mature  (ripe)        -            -            -            -            -            -            -  187 

Posterior  polar  (deposit  upon  the  posterior  lens-capsule)           -  186 

Pyramidal  (anterior  polar)             -            -            -            -            -  186 

Secondary               -            -            -            -            -            -            -  192 

Soft 188 

Total          - 187 

Traumatic               -------  192 

Zonular  (lamellar)              -            -            -            -            -            -  184 

Caustics,  Use  of--------  54 

Cellulitis  orbitse,  Phlegmonous  inflammation  of  the  orbital  tissues             -  77 

Cerebro  spinal  meningitis    -------  281 

Chalazion,  Tarsal  tumor       -------  ^^g 

Chemosis,  CEdematous  swelling  of  the  ocular  conjunctiva               -            -  161 

Chiasma  of  the  optic  nerves              .--_._  261 

Choriocapillary  layer            -            -            -            -            -            -            -  15 

Choroid,  Anatomy  of  the      -------  14 

Choroiditis,  Inflammation  of  the  choroid    -            -            -            -            -  158 

Areolar               ------«  1^8 

Central  (chorio-retinitis)            -            -            -            -            -  160 

Disseminate       -            -            -            -            -            -            -  158 

Fibrino-Plastic               -            -            -            -            -            -  158 

Metastatic          -            -.           -            -            -            -            -  162 

Purulent              -------  161 

Serous                 -            -            -            _        .    -            -            _  161 

Tubercular         -            -            --            -            -            -  163 

Cilia,  Eyelashes        --------  6 

Ciliary  body               -            -            --            -            -            -            -  15 

Muscle           -            -            -            -            -            -            -            -  16 

Nerves           --------  i^ 

Processes       --------  18 

Circulatory  apparatus,  diseases  of                -----  273 

Cocaine  anaesthesia  -  -  -  -  .  -  -      84, 288 

Cocainum  hydrochloricum,  Use  of               -            -            -            -            -  312 

Cold  applications      -  -  -  -  -  -  -  -82 

Coloboma,  Fissure  of  the  iris.  Congenital     -  -  -  -        '    -   -        268 

Of  the  choroid            ,            _            -            -  269 

Of  the  lids      -----  270 

Rupture  of  the  sphincter  iridis,  Traumatic         -            -            -  152 

Color-blindness,  Lack  of  perception  of  certain  colors,  Congenital              -  285 

Acquired    -            -            -            -            -            -            -  182 

Examination  of      -            -            -            -            -            -  285 

Color  perception        -            -            -            -._            -            -            -  39 

Cones  of  the  retina                -            -            -            --            -            -  21 


320  OPHTHALMOLOGY. 

Conical  cornea          -            -.          -            -            -            -            -            -  131 

Conjunctiva,  Ocular              .____..  g 

Palpebral         -..            -            -            -            -            -  5 

Fornix  of  the  _  -  _  .  _  ^      ^ 

Conjunctivitis,  Inflammation  of  the  conjunctiva       -            -           -            -  94 

Catarrhal,  Acute       .._---  95 

Chronic                 -  .         -            -            -            -  94 

Croupous  (membranous)       -----  loi 

Diphtheritic               -            -            -            -            -            -  102 

Gonorrhoeal               ______  98 

Granular,  Acute       -           -            -            -            --  106 

Chronic    -            -           -           -            -            -  103 

Phlyctaenular             -            -            -            -            -            -  iii 

Purulent,  Acute        ------  98 

Chronic    -            -            -            -            -            -  loi 

Of  the  newly  born     ------  79 

Pustular         -            -            -            -            -            -            -  112 

Constipation              -            -            -            -            -_            -            -  274 

Contact  lenses           -            -            -            -            -            -            -            -  137 

Contusion,    ---------  218 

Convergence              --_.----  289 

Convergent,  Strabismus        -------  233 

Cornea,  Anatomy  of  the        -------  9 

Comeo-scleral  margin.  Anatomy  of  the        -            -            -            -            -  12 

Copper,  Use  of  the  sulphate  of         -----            -  85 

Crescent  in  myopia                _---__-  235 

Crystalline  lens.  Anatomy  of  the      ------  24 

Cyclitis,  Inflammation  of  the  ciliary  body                -            -            -            -  155 

Fibrino-plastic        -            -            -.-            -            -            -  155 

Gummatous             -            -            -            -            -            -            -  156 

Purulent      -            --            -            -            -            -            -  156 

Serous         --------  135 

Cyclitic  membtane,  Membrane  formed  behind  the  crystalline  lens  by  a 

fibrino-plastic  cyclitis    -            -            -            -            -            -            -  155 

Cyst  of  the  orbit       -  -  -  -  -  -  -  -79 

Conjunctiva        -           -           -            -            -            -            -  120 

Iris         -            -           -            -            -           -            -            -  153 

DAKRYO-ADENITIS,  Inflammation  of  the  lachrymal  gland        -           -  64 

Dakryo-cystitis,  Inflammation  of  the  lachrymal  sack,  Catarrhal      -            -  68 

Purulent       -            -  68 

Dakryops,  Cystoid  distention  of  the  lachrymal  gland          -            -            -  67 

Descemet's  membrane,  Posterior  limiting  membrane  of  the  cornea            -  10 

Detachment  of  the  ciliary  body  from  the  sclerotic               -           -            -  155 

Retina  from  the  choroid             -            -            -            -  169 

Development  of  the  eye        -------  264 

Diabetes  mellitus      --------  285 

Digestive  organs.  Diseases  of  the    ------  274 

Dilatation  of  the  pupil           -            -            -            -            -            -            -  153 

Dilator  muscles  of  the  iris     -------  20 


INDEX.  321 

Diplopia,  Double  vision        -------  247 

Examination  of    ------            -  42 

Heteronymous       -------  247 

Homonymous        -------  247 

Diphtheria  of  the  throat        -_---._  250 

Discharge,  Removal  of  from  the  conjunctival  sac                -            -            _  g^ 

From  the  eye-lashes         ------  g^ 

Discission  of  the  lens-capsule           ------  299 

Dislocation  of  the  crystalline  lens,  Congenital          _            -             -            -  ig^ 

Acquired             -             .             _             -  j^^ 

Distichiasis,  Irregular  position  of  the  eye-lashes     -             -             -             -  ^3 

Divergent  strabismus            -_--___  237 

Duboisine,  Use  of-            -             -             -            -            -             -            -  116 

Dura  mater  sheath  of  the  optic  nerve            _            _            _            -            _  20 

ECTACTIC  scar      -            -            -            -            -            -            -            -  212 

Ectopia  lentis,  Congenital  dislocation  of  the  crystalline  lens           -            -  193 

Ectropium,  Eversion  of  the  eyelid                 _             -             _            _            _  ^6 

Operations  ■  ------      57>  302 

Eczema  of  lids           __.---.-  44 

Electricity,  Use  of  in  opacities  of  the  vitreous  body            -            -            -  197 

Embolism  of  the  central  retinal  artery          -----  167 

Emmetropia,  The  condition  in  which  the  eye  at  rest  is  focussed  for  paral-     • 

lei  rays                .-_.----  225 

Emphysema  of  the  eyelids                ------  62 

Orbit      -------  79 

Endocarditis,  Fibrinous        -------  273 

Entropium,  Inversion  of  the  eyelid               -----  ^^ 

Operations         -  -  -  -^  -  -  -      55>  302 

Enucleation  of  the  eyeball,                -    •        -            -            -            -            -  291 

Epicanthus     ---------  271 

Epiphora,  Tear-droppkig      --------  67 

Episcleritis,  Inflammation  of  the  episcleral  tissue,               -            -            -  1^9 

Epithelioma  of  the  lid            ------            -  50 

Of  the  conjunctiva          ------  120 

Erysipelas  of  the  face            -------  279 

Eserine,  Use  of  the  sulphate  of         ------  312 

Examination  of  the  eye.  Methods  of             -            -            -            -            -  31 

Excavation  of  the  optic  nerve,  Atrophic      -            -            -            -            -  187 

Glaucomatous          -            -            -             -  204 

Physiological           -            -            -            -  21 

Exophihalmus,  Protrusion  of  the  eyeball      -----  75 

Pulsating       -------  273 

Extraction  of  cataract,            -            -            -            -            -            -            -  297 

Everting  the  eyelids  for  examination  or  treatment               _            -            -  32 

Evisceration,              -            -            -             -            -            -            -             -  291 

Eye-douche  -  -  -  -  -  -  -  -82 

Eye-lashes    ---------  6 

Eye-lids,  Anatomy  of  the                  -            -            -            -            -            -  6 


322  OPHTHALMOLOG  V. 

FAR-POINT,  Point  for  which  the  eye  at  rest  is  focussed               -            -  226 

Far-sight        -_---_---  229 

Fascette,        ---------  132 

Fistule  of  the  lachrymal  sack            ------  69 

Fluids,  Course  of  the,  Within  the  eyeball    -            -            -            -  25 

Focal  illumination    --------  35 

Focal  interval  of  rays  refracted  by  an  asymmetrical  surface             -            -  238 

Fontana's  cavities,  Anatomy  of-            -            -            -            -            -  11 

Obliteration  of  in  glaucoma        -            -             -            -  204 

Foreign  bodies  in  the  ciliary  body                -            -            -            -            -  215 

Conjunctiva                -            _            _            -            -  87 

Cornea           ------  214 

Iris    -------  214 

Lens               ------  214 

Vitreous  body            -----  214 

Fossa  lachrymalis     -            -            -            -            -            --            -  2 

Fovea  centralis  of  the  retina,            ------  23 

Fracture  of  the  walls  of  the  canalis  opticus,              -            -            -            -  181 

Lamina  papyracea  of  the  OS  ethmoi dale            -  79 

GANGLION  Gasseri           --....-  279 

Glasses,  Concave  for  myopia            ------  307 

Convex  for  hypermetropia               .            -             _            _            _  306 

'                      Presbyopia         -            -             -            -            -             -  308 

Cylindrical  for  astigmatism             -            _             -            -            _  307 

Hypeibolic  for  conical  cornea        -            -            -            -            -  137 

Protective,  Against  injuries  and  light         -            >            .            .  310 
Glaucoma,  A  disease  characterized  by  an  increase  of  the  intra-ocular  ten- 
sion and  pathological  excavation  of  the  optic  papilla          -  199 
Absolutum,  Absolute  blindness  from  glaucoma              -    ,        -  203 
Acute  inflammatory         ------  202 

Chronic  inflammatory     -             -             -            -            -            -  202 

Chronic  simple                 --_-__  200 

Fulminans           -            -            _    ,        -            -            -            .  202 

Haemorrhagic       -------  203 

Secondary            ---_-_.  203 

Theories  of-------  206 

Glioma  of  retina        -            -            -            -            -            -            -            -  175 

Gonorrhseal  iritis       -            -            -            -            -            -            -            -  150 

Gout              -            -            -            -            --            -            -            -  298 

Graefe's  cataract  extraction               -            -            -            -            -            -  298 

Granular  eyelids        -            __            »            -            -            .            -  103 

Granuloma  of  the  conjunctiva           -            -            -            -            -            -  120 

Iris           -------  211 

Graves'  disease,        --------  276 

Grippe 251 

HEART  Diseases                -           -            -            -            -            -            -  273 

Headache      -            -            -            -            -            -            --            -  241 

Hemeralopia,  Night-blindness          -            -            -            -            -            -  172 


INDEX.                              .  323 

Hemianopsia,  Blindness  of  one-half  of  the  eye  from  brain  disease              -  260 

Bilateral          __.----  262 

Heteronymous           ------  263 

Homonymous             -            -            -            -        ,   -            -  262 

Unilateral       -            -            -            .             ...  263 

Haemorrhage  into  the  anterior  chamber      -            -            -            -            -  217 

Choroid          ------  166 

Conjunctiva                -            -            -        .    -            -  116 

Orbit 76 

Retina 175 

Vitreous  body            -            -            -            -            -  198 

Herpes  zoster  --------      44,  279 

Heterochromia,         __..----  271 

Heterophoria,            ._-__---  43 

Hoeurteloup's  artificial  leech            -            -            -            -            -            -  83 

Holmgren's  method  for  the  detection  ef  color-blindness    -            -         ^  -  285 

Homatropine,  Use  of  the  hydrobromate  of              -            -            -            -  3^^' 

Hordeolum,  Stye       --------  48 

Horner's  muscle        --------  27 

Hyaloid  artery           -             -             -            -            -            -             --  266 

Hyalitis,  Inflammation  of  the  vitreous  body            -            -            -            -  196 

Hyoscyamme,  Use  of-------  3^^^ 

Hyoscinum  hydroiodicum,  Use  of    ------  312 

Hypersemia  of  the  brain        -------  258 

Conjunctiva         ------  93 

Episcleral  tissue             -----  146 

Optic  papilla      -            -            -            -            -            -  177 

Retina    -------  167 

Hypermetropia,  The  condition  in  which  the  eye  at  rest  is  focussed  for 

convergent  rays             -----  229 

Latent,  Part  hidden  by  accommodation    -            -            -  230 
Manifest,  Part  detected  without  paralyzing  the  accommo- 
dation               ------  230 

Total,  The  sum  of  the  manifest  and  the  latent  h)  perme- 

tropia    -------  230 

Hypertrophy  of  the  left  ventricle  of  the  heart           .            _            -            -  273 

Hypopyum,  Pus  in  the  anterior  chamber     -----  148 


INCARCERATION  of  the  iris      ------  210 

Infectious  diseases    -            -            -^-            -            -            -            -  279 

Injuries  to  the  ciliary  body                -            -.           -            -            -            -  213 

Conjunctiva                -            -            -            -            -            -  114 

Cornea           -------  137 

Crystalline  lens          -            -            -            -            -            -  192 

Eyelids           -------  62 

Iris    --------  152 

Optice  rierve              -            -            -            --            -  214 

Inoculation  of  pus  lor  the  cure  of  trachoma             -            -            -            -  no 

Inspergation  of  medicinal  powders                -            -             .            _             .  86 

Instillation  of  medicated  fluids         --_-.-  83 


324  OPHTHALMOLOGY. 

Insufficiency  of  the  internal  recti  muscles    -            -            -            -            -  236 

Examination  for           -            -            -            -            -            -  42 

Intervaginal  spaces  of  the  optic  nerve          -            -            -            -            -  257 

Intoxication               -            -            -            -            -            -            -            -  282 

Intra-ocular  tension,  Examination  of  the    -----  39 

Increase  of      -            _            -            -            _            _  i^g 

Iodoform,  Use  of      -            -            -            -            -            _          .  _            -  ^13 

Iris,  Anatoay  of  the              ---._-_  18 

Iridectomy,  Removal  of  a  piece  from  the  iris          -            _            .            _  295 

Iridencleisis,  Artificial  incarceration  of  the  iris  in  the  cornea          -            -  185 

Irideremia,  Absence  of  the  iris,  Traumatic               -            -            -            -  213 

Iridodialysis,  Partial  detachment  of  the  iris  from  its  ciliary  insertion          -  152 

Iridodonesis,  Tremulous  iris  from  lack  of  support  from  the  crystalline  lens  35 

Iridotomy,  Operation  after  plastic  iritis  or  irido-cyclitis      -            -            -  296 

Iritis,  Inflammation  of  the  iris           ------  143 

Fibrioo-plastic             -            -            -            -            -            -            -  144 

Gummatous     -            -            -            -            --            -            -  149 

Purulent           --------  148 

Rheumatic        --_.-_--  144 

Serous               -            -            -            --            -            -            -  147 

Syphilitic         -            -            -            -            -            -            -            -  149 

Tubercular       --            -             -            -            -            -            -  149 

Ischsemia  of  the  retina          -            -            -            -            -            -            -  167 

Isolation        ---------  87 

JEQUiRITY,  Abrusprecatorius,Useofthe            -   "        -            -            -  no 

KERATITIS,  Inflammation  of  the  cornea               -            -            -            -  122 

Bullosa          -            -            -          •-            -            -»          -  124 

Dentritica      -            -            -            -            -            -            -  124 

Fascicular     -            -            -             -         ,    -             -             -  123 

Filamentosa              -            -            -            -            -            -  124 

Malarial        -------  132 

N  euro-paralytic         -            -            -            --            -  133 

Parenchymatous         -             -             -            -            -            -  125 

Phlyctsenular              -            -            -             _             -             _  123 

Pustular         -------  123 

Syphilitic      -            -            -            -            -            -            -  125 

Knapp's  method  of  blepharoplasty  by  sliding  flaps              -            -            -  51 

Transplanting  pterygium           -            -            -            -  119 

LACHRYMAL  Apparatus               ------  26 

Canaliculi               --____  26 

Caruncle    -------  5 

■    Conjunctivitis         ------  97 

Duct           ---.-.-  27 

Gland         -------  27 

Papilla        -------  6 

Puncta        -            -           -            -            -            -           -  6 

Sack           -            -.          -            -            -            -            -  27 


INDEX.  325 

Lagophthalmus,  Inability  to  close  the  eyelids          _            -            _            -  60 

Lamina  cribrosa  of  the  sclerotic       ------  9 

Vitrea  of  the  choroid            -            -            -            -             -            -  15 

Leeches,  Application  of                     ------  83 

Lens,  Crystalline       --------  24 

Capsule  -  -  -  -  -  -  -  -24 

Epitheliun^i      --------  24 

Leptothrix,  Vegetable  parasite  found  in  the  lachrymal  canaliculus              -  67 

Leukaemia     ---------  275 

Levator  palpebrae  superioris  muscle              -----  8 

Ligament,  External  palpebral          ------  8 

Internal  palpebral            _---_-  8 

Pectinatum  of  the  iris      -            -             -            -             -            -  n 

Sus  ensory  of  the  crystalline  lens            _            -            -            -  24 

Light-sense                -            -            --            -            -            -            -  38 

Limbus  of  the  cornea            -------  8 

Limiting  membranes  of  the  cornea                _             -             -             .            -  10 

Lupus  of  conjunctiva             -            -            -            -            -            -            -  115 

L>mphangiectasia  of  conjunctiva     -            -             -            -            -         •   -  117 

MACULA  lutea  of  the  retina,  Point  of  acute  vision           -            -            -  23 

Of  the  cornea    -------  123 

Madarosis,  Loss  of  eyelashes            ------  45 

Malarial  fever            --------  280 

Malformations  of  the  eye      -------  266 

Malingering              -            --            -            -            -            -            -  284 

Measles         ---------  279 

Medullated  nerve  fibres        -------  270 

Meibomian,  Tarsal  glands                -            -            -            -            -            -      ,  6 

Metamorphopsia,  Distorted  vision       .--.--  160 

Miosis,  Contraction  of  pupil              -             -            -            -            -    .        -  153 

Motility  of  the  eyeballs,  Examination  of      -            -            -            -            ^  42 

Mucocele,  Distension  of  the  lachrymal  sack  by  a  mucoid  fluid       -            -  68 

Muscae  volitantes.  Spots  floating  before  the  eye      -            -            -            -  ^96 

Muscles,  External  of  the  eyeball       -            -            -            -  .          _            -  244 

Mueller's  fibres  of  the  retina              ------  23 

Mydriasis,  Dilata  ion  of  the  pupil  with  immobility              -            -            -  153 
Myopia,  Ihe  condition  in  which  the  eye  at  rest  is  focussed  for  divergent 

rays        ---------233 

Myxoma  of  01  tic  nerve         -------  183 

NASAL  DUCT  for  the  drainage  of  the  tears          -            -            -            -  27 

Nearsightedness       --------  233 

Near-point,  Nearest  point  for  which  the  eye  can  accommodate      -            -  228 

Necrosis  of  the  orbital  walls              ------  184 

Nephritis       ---------  275 

Nerves  of  the  orbit  and  eye               ------  29 

Neurectomy,  Optico-ciliary,  Removal  of  a  piece  of  the  optic  nerve  and  the 

ciliary  nerves  near  the  eyeball      -            -            -            -  223 

Of  the  infra-orbital  nerve  and  supra-orbital  nerve      -            -  60 


326  OPHTHALMOLOGY. 

Neuritis  optic,  Inflammation  of  the  optic  neive        -            -            -            -  I77 

Ascendent        -            -           -            -            -           -           -  I77 

Descendent      -            -            -           -           -           -            -  I79 

Interstitial        -------  i8o 

Nenro-reiinitis,  In6ammation  of  the  optic  nerve  and  retina             -            -  177 
Neurotomy,  Optfco-ciliary,  Severing  of  the  optic  nerve  arid  the  ciliary 

nerves  from  the  eyeball              __----  223 

Nitrate  of  silver,  Use  of        -------  314 

Nystagmus,  Involuntary  oscillation  of  the  eyeball                -            -            -  255 

OBLITERATION  of  the  lachrymal  sack                -            -            "            "  74 
Oblique  illumination  of  the  anterior  third  of  the  eyeball  by  means  of  a 

convex  lens        --------  35 

Occlusion  of  pupil     -            -            -            -            -            -            --  I44 

Ocular  fissure,  Foetal              ---__--  265 

Vesicle,  Primary        -------  264 

Secondary                 ------  264 

QEdema  of  the  conjunctiva                -            -            -            -            -            -  115 

Of  the  lids                 --_-..-  44 

Of  the  optic  papilla             -            -            -                         -            -  259 

Ointments,  Application  of-            -            -            -            --            -  86 

Onanism        ---------  276 

Opacities  of  the  cornea         -------  134 

of  the  vitreous  body           -            -            -            -            -            -  I79 

Ophthalmoplegia  externa      -             -             -             -            -            -            -  248 

Ophthalmoscope,  Use  of  the             ------  40 

Optic  foramen,  External  orifice  of  the  cainalis  opticus          -            -             -  3 

Nerve,  Anatomy  of    -            -            -             -           .-       .      -            -  20 

Papilla             ------.           w            -  21 

Ora,  Serrata  of  the  retina      -------  21 

Orbicularis  muscle  of  the  eyelids      ------  7 

Orbit,  Anatomy  of  the          -            -            -            -            -            -            -  i 

diseases  of  the            _--_.--  75 

Osteoma  of  the  orbit             __._-_-  81 

PANN US,  Vascularization  and  dimness  of  the  cornea        -            -            -  105 

Panophthalmitis,  Inflammation  of  all  the  tissues  of  the  eyeball      -            -  161 

Papillitis        ---------  177 

Paracentesis  of  the  cornea    -------  292 

of  the  sclerotic  for  detachment  of  the  retina                -            -  171 

Paralysis  of  the  accommodation        -            -            -            -             -            -  242 

External  muscles  of  the  eyeball      -            _            -            -  248 

Muscles  of  the  eyelids        -            -            -            -            -  60 

Pars  ciliaris  retinae     -            -            -            -            -            --            -  17 

Pediculi,  Crab-lice,  in  the  eye-lashes            -            -            -            -            -  47 

Pemphigus     -             -             -            -            -            -            -            -            -  113 

Periostitis  of  the  orbit            -            -            -            -            -            -            -  75 

Periosteum  of  the  orbit         -------  3^ 

Phlegmonous  abscess  of  the  eyelid               -----  49 

Inflammation  of  the  orbital  tissue      -            -            -            -  77 

Photophobia,  Dread  of  light  in  phlyctsenular  conjunctivitis             -            -  112 


INDEX.  327 

Photopsia,  Subjective  perception  of  light-flashes,  etc.          -            -      ,     -  159 

Phthiriasis     ---------  47 

PhysiologicaF  excavation      -            -            -            -            -            -            -  21 

Pia  mater  sheath  of  the  optic  nerve              -----  20 

Pigmentary  epithelium,  Anatomy  of  the       -            -             -            -            -  15 

Pigmentation  of  the  retina  from  choroido-retinitis                -            -            -  150 

Pilocarpine,  Use  of  the  muriate  of  in  detachment  of  the  retina       -            -  170 

Pinguecula,  Small  connective  tissue  tumor  of  the  conjunctiva         -            -  117 

Polyf  us  of  the  lachrymal  canaliculus            -----  67 

Nose               -------  272 

Posterior  chamber,  Space  bound  by  the  crystalline  lens,  zonule  of  Zinn, 

ciliary  body  and  iris       -------  25 

Presbyopia,  Physiological  loss  ot  elasticity  of  the  crystalline  lens,  and 

consequent  impairment  the  accommodation     -            -            -             -  241 

Prisms,  Use  of  for  detecting  simulated  blindness    -            -            -            -  284 

Prolapse  of  the  iris  through  a  corneal  wound           -            -            -            -  210 

Prodromal  stage  of  glaucoma            .__---  200 

Pseudo-glioma           -            --            -            -            -            -            -  176 

Pterygium,  Triangular  fold  of  conjunctival  tissue  encroaching  upon  the 

cornfea             -            -             -            -             -             -            -  117 

Operations           -            -            -             -             -            -            -  119 

Theories  of  origin           -            -            -            -            -            -  118 

Ptosis  of  the  upper  eyelid.  Inability  to  raise  it         -            -            -            -  57 

Operations          -            -            -            -          .  _  157 

Puerperal  fever          -            -            -            -            -            -            -            -  162 

Pupillary  membrane.  Due  to  fibrino-plastic  iritis    -            -            -            -  144 

Remnants  of  foetal      --_--.    368 

Pyoktanine,  Use  of-           -           -           -           -            -           -           -  313 

Pyaemia         ---------  281 

RECURRENT  Fever          -            -            -            -            -            -            -  280 

Red-green  blindness              -------  285 

Refraction     ---------  225 

Remedies  in  substance,  Use  of         -----            -  85 

Respiratory  apparatus,  Diseases  of  the        -            -            -            -            -  272 

Retina,  Anatomy  of  the         -------  21 

Retinitis,  Inflammation  of  the  retina            _            -            _            -            .  171 

Albuminuric          -            -            -            -            -            -            -  173 

Haemorrhagic        -            -            -            --            _            -  175 

Leukaemic              -------  275 

Pigmentary            -            -            -            -            -            -            -  171 

Proliferans             -                          -            -            -            -            -  197 

Syphilitic               -            -           -            -            --            -  172 

Retinal  purple,  Substance,  secreted  by  the  pigmentary  epithelium              -  15 

Rheumatism              -----___  283 

Rods  of  the  retina    -------  21 

Rupture,  Isolated  of  the  choroid      -            -            -            -            -            -  165 

SiEMISCH'S  operation  for  ulcer  and  abscess  of  the  cornea            -            -  130 

Scarlet  fever               --------  279 


328  OPHTHALMOLOG  V. 

Schlemm's  canal  in  the  corneal-scleral  tissue           -            -            -            -  1 1 

Scleritis,  Inflammation  of  the  sclerotic          -            -            -            -            -  139 

Sclerosis  of  the  spinal  cord               -            -            -            -            -*-  182" 

Sclerotic,  Anatomy  of  the    -------  8 

Sclerotomy                 __--.---  294 

Scotoma  central,  Pathological  blind  spot      -            -            -            -            -  180 

Scrophulosis               ___-_..-  283 

Seclusion  of  pupil      -            -            -            -            -            -            -            -  145 

Septicaemia                 .._-----  281 

Shrinkage  of  the  conjunctival  sack                -           -            -            -            -  105 

Eyeball      -------  162 

Silver,  Use  of  the  nitrate  of  in  conjunctivitis            -            _            -            -  96 

Skin  diseases             -            -            -            --            -            -            -  279 

Small  pox      -            --            -            -            -            -            -            -  279 

Spasm  of  the  accommodation            ------  243 

Sphincter  muscle  of  the  iris               -            -            -            -            -            -  19 

Spongy  exudation      -            -            -            -            -            -            -            -  147 

Staphyloma,  Union  between  a  part  of  the  cornea  or  sclerotic  with  a  part 

of  the  uveal  tract  with  stretching,  of  the  cornea            -            -            -  135 

Sclerotic        -          •  -            -  140 

Stillicidium  lacrimarum,  Tear-dropping      -----  67 

Stilling's  canal  in  the  vitreous  body              -            -            -            -            -  25 

Strabismus,  Paralytic             -----             ..            .  249 

Muscular              -            -            -             -            -            -             -  252 

Convergent         -             -             -             -             -             -            -  233 

Divergent           -------  237 

Strictures  of  the  lachrymal  drainage  apparatus        -            -            -            -  70 

Symblepharon  anterius,  Union  between  the  lid-margin  and  the  eyeball     -  116 
Posterius,  The  union  reaches  down  into  the  fornix  of  the 

conjunctiva          -            -            -            -            -            -  116 

Operations    -            -            -            -            -            -            -  301 

Sympathetic  Inflammation,  An  inflammation  caused  in  one  eye  by  a  dis- 
ease, usually  of  traumatic  origin,  in  the  fellow-eye          -  219 
Irido-choroiditis            ------  222 

Irido-cyclitis                 ------  222 

Iritis     --------  222 

Irritation           -            -            -            -            -            -            -  221 

Keratitis            -            -            -            -            -            -            -  223 

Neuritis             -            -            -            -            -            -            -  222 

Neuro-retinitis              -            -            -            -            -            -  222 

Synchysis,  Liquefaction  of  the  vitreous  body            -            -            -            -  196 

Scintillans,  Containing  crystals  of  cholesterine,  etc        -            -  197 

Synechia,  Adhesion  of  the  iris.  Anterior      -----  131 

Circular        -            -            -            -            -  144 

Posterior      -            -            -            -            -  144 

Syphilis          -            -            --            -            -            -            -            -  281 

TABES  Dorsalis       -            -            -            -            r            -  "        -            -  182 

Tarsal  tissue,  Anatomy  of  the            __.--.  6 

Tarso-orbital  fascia                -            -            -            -            --            -  5 


INDEX.  329 

Tarsorraphy,  Operation  for  shortening  the  palpebral  fissure           -            -.  (yo 

Tatooing  the  cornea              _._-_--  134 

Teleangiectatic  tumors  of  the  eyelid              _            _            _            -            _  53 

Tenon's  capsule,  Anatomy  of------  3 

Space  -  -  -  -  -  -  -  -4 

Tenonitis,  Inflammation  of  Tenon's  capsule            _            _            _            _  78 

Tenotomy      -            -            -            -            -            --            -            -  288 

Partial       --------  290 

Test-types,  Snellen's,  Letters  seen  under  a  visual  angle  of  five  minutes, 

u&ed  to  determine  the  acuteness  oi  vision         -            -            -            -  227 

Thrombosis  of  the  central  retinal  vein          -----  168 

Trachoma,  Inflammation  of  the  conjunctiva  characterized  by  the  formation 

of  granules          --------  103 

Transplantation  of  flaps  for  blepharophasty             .            -            -            -  52 

for  the  cure  of  symblepharon         -            -            -  301 

Trichiasis,  Irregular  position  of  the  eye-lashes        _            -            -            -  53 

Operations           .__----  55 

Tropa-cocame           -            -            -            -            -            -            -            -  312 

Tubercle  in  the  choroid        -            -                         -            -            -            -  163 

Iris                -------  149 

Of  conjunctiva        -            -            -            -            --            -  115 

Tuberculosis  of  the  lungs      -            -            -            -            -            -            -  281 

Tumors  of  the  ciliary  body                -            -            -            -            -            -  157 

Choroid        -            -             -             -            1            -            -  163 

Conjunctiva               --            -            -            -            -  117 

Cornea          -            -            -            -                         -            -  138 

Eyelids  -  -  -  -  -  -  -    •         5° 

Episcleral  tissue        -            -            -^           -            -            -  142 

Iris 153 

Lachrymal  caruncle               -            _            _            -            -  74 

Lachrymal  gland      -----  66 

Optic  nerve               -            -            -           -            -       •    -  183 

Orbit             -------  79 

Retina           -                         -----  175 

Tarsus            -------  49 

Typhus,  Abdominal               _._-_-_  280 

ULCER  ot  the  conjunctiva  after  diphtheria             -            -            -            -  103 

Cornea          -------  130 

Eyelid           -------  50 

Uro-poetic  apparatus,  Diseases  of  the          _            -            -            .            -  275 

Uveal  tract,  Anatomy  of  the              -            -            -            -            -            -  13 

VARIOLA  of  lid -           -           -  44 

Varioloid  of  lids         -            -             -            -            -            -            -            -  44 

Vascular  tumors  of  the  eyelid           -            -            -            -            -            -  53 

Vein,  Central,  Retinal           -            -            -            -            -            -            -  24 

Venae  vorticosae          -             --            -                         -            --  15 

Visual  field,  Examination  of              ------  37 

Vitreous  body            -__-_-_-  25 


330  OPHTHALMOLOGY. 

WARM  Applications            -_..---  83 

Warts  on  the  eyelid               ______  ^o 

Whooping-cough      ____--__  272 

Wild  hair ^7 

Wire-mask    ---------  90 

XANTHELASMA;  Small,  slightly    elevated,  yellowish  tumors   of  the 

skin  of  the  eyelid            _-___-.  50 

Xerophthalmus,  Dryness  of  the  eye              -            -            -            -            -  106 

YELLOW-BLUE  blindness             -           -           -           -           -            -  285 

Yellow  oxide  of  mercury,  Use  of      -            -            -            -            -            -  314 

Yellow  spot  of  the  retina      -_--__-  23 

ZINC,  Use  of  the  sulphate                -            .            .            _            _            .  314 

Zonule  of  Zinn,  Suspensory  ligament  of  the  crystalline  lens            -           -  25 


14  DAY  USE 

RKl'URN  TO  DESK  FROM  WHICH  BORROWED 

OPTOMETRY  LIBRARY 

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on  the  date  to  which  renewed. 

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